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Pre-Auth Tool | Ambetter from Sunshine Health
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.
The following services (identifiable by procedure code search) need to be verified by Evolent: Cardiac Imaging, Complex Imaging, MRA, MRI, PET, and CT scans; Speech, Occupational and Physical Therapy (excluding chiropractor specialty providers – no authorization required); Effective for dates of service 1/1/2024 forward, Musculoskeletal services for the spine, shoulder, hip and knee.
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
Behavioral Health/Substance Abuse need to be verified by Sunshine Health
Oncology Biopharmacy, Radiation Oncology drugs, and administration of Radiation Oncology need to be verified by Evolent.
Drug authorizations need to be verified by Envolve Pharmacy Solutions; for assistance call 866-399-0928.
Post-acute facility (SNF, IRF, and LTAC) prior authorizations need to be verified by CareCentrix ; Fax 877-250-5290
For Chiropractic providers, no authorization is required.
Services provided by Out-of-Network providers are not covered by the plan. Join Our Network
Note: Services related to an authorization denial will result in denial of all associated claims.
Are Services being performed in the Emergency Department?
|Types of Services
|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?