Pre-Auth Check Tool | Ambetter from Western Sky Community Care
Pre-Auth Needed?
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 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 (excluding chiropractor specialty providers – no authorization required); Pain Management.
Musculoskeletal surgical services need to be verified by TurningPoint.
Effective 1/1/2024, the following Substance Use Disorder services require Notification of Admission within 1-Business Day: Residential Treatment Services (ASAM Level 3.1-3.5), Partial Hospitalization Program (PHP) (ASAM Level 2.5), Intensive Outpatient Program (IOP) (ASAM Level 2.1).
Non-participating providers must submit Prior Authorization for all services.
For non-participating providers, Join Our Network
Are Services being performed in the Emergency Department?
| Types of Services | YES | NO |
|---|---|---|
| Are oral surgery services being provided in the office? | ||
| 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? | ||
| Is the member receiving Gender Reassignment services? |