Pre-Auth Tool | Ambetter from Superior HealthPlan

 

Pre-Auth Needed?

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DISCLAIMER:

All attempts are made to provide the most current information on the Pre-Auth Needed 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. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.

Vision services, including all services rendered by an Optician, Ophthalmologist, or Optometrist need to be verified by Envolve Vision

Dental services need to be verified by Envolve Dental

The following services (identifiable by procedure code search) need to be verified by Evolent:  Complex Imaging, MRA, MRI, PET, and CT scans; Speech, Occupational and Physical Therapy services (Chiropractor specialty providers excluded and follow authorization requirements with the health plan); Genetic Testing; Pain Management.  Effective for dates of service 1/1/2024 forward, Spinal Cord Stimulators and Musculoskeletal services for the spine, shoulder, hip and knee.

Cardiac, Sleep Study Management and Ear, Nose and Throat (ENT) procedures need to be verified by TurningPoint.  Musculoskeletal services for DOS prior to 1/1/2024 will continue to be verified by TurningPoint.  Please contact TurningPoint by phone (1-855-336-4391) or fax (1-214-306-9323).

 

Services provided by Out-of-Network providers are not covered by the plan. Join Our Network

 

Are Services being performed in the Emergency Department?

Types of Services YES NO
Are the services being performed or ordered by a non-participating provider (professionals/facilities)?
Is the member being admitted to an inpatient facility?
Are anesthesia services being rendered for dental surgeries?
Are oral surgery services being provided in the office?
Is the member receiving Gender Reassignment services?