DISCLAIMER: While we strive to provide the most up-to-date information on the Pre-Auth Needed Tool, please remember that prior authorization is not a guarantee of payment. Claim payment is subject to member eligibility, covered benefits, provider contracts, and accurate coding and billing practices. Always consult the provider manual for detailed information. If you are unsure whether prior authorization is required, we encourage you to submit a request to ensure accuracy.
For vision services, verification is required through Centene Vision Services.
For dental services, please verify requirements with Centene Dental Services.
The following services necessitate verification via Evolent: Complex Imaging, including MRA, MRI, PET, and CT scans; Musculoskeletal services specifically for shoulder, hip, spine, and knee surgeries; Pain Management interventions; and Spinal Cord Stimulators. Please note that Chiropractic specialty providers are not managed by Evolent.
For Medical Oncology services and Biopharmacy supportive drugs, verification should be conducted through Evolent.
Services rendered by Out-of-Network providers are generally not covered by the plan unless prior authorization has been obtained. Join Our Network to ensure seamless coverage for your patients.
Emergency Department Services
Services performed in the Emergency Department or for Emergent Transportation do not require prior authorization. This exception is in place to ensure timely and critical care access for our members in emergency situations.
| Service Type Inquiry | Prior Authorization Required? |
|---|---|
| Services by a non-participating provider (professionals/facilities)? | YES |
| Inpatient facility admission? | YES |
| Anesthesia services for dental surgeries? | YES |
| Oral surgery services in an office setting? | YES |
| Gender Affirming services? | YES |
These services listed above typically require prior authorization. To initiate the authorization process, please Login Here to submit your request through our secure provider portal.
Service Code Lookup
To quickly check if a specific service code requires prior authorization, please utilize our Coordinated Care Precert Tool available in the provider portal.
Submit a Prior Authorization
Ready to submit a prior authorization request? Login Here to access the coordinated care precert tool and ensure timely processing for your patients’ care.
