Prior Authorization Tool

DISCLAIMER: All attempts are made to provide the most current information on the Prior Authorization Search Tool. However, this does NOT guarantee payment. Payment of claims is dependent on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the Provider Manual on the Provider Materials page. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.

Inpatient services require notification within 24-hours of admission.
Prior to submitting requests for the following services:

• Vision services need to be verified by Envolve Vision Services
• Dental services need to be verified by DentaQuest/MCNA

Medicaid Members

• Family Planning services with a contraceptive management diagnosis do not require an authorization whether the Provider is In-Network or Out-of-Network.

CHIP Members

• Family Planning services with a contraceptive management diagnosis are not a benefit.
• THSteps checkups do not require an authorization whether Provider is In-Network or Out of Network.

List of Services that require Prior Authorization

• Are services being provided by an out-of-network Provider?
• Is the member being admitted to an inpatient facility?
• Is the member receiving oral surgery services?
• Is the member receiving plastic and reconstructive surgeon services?
• Is the member receiving venous surgical procedures?