Medicare Pre-Auth Needed?

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 upon eligibility, covered benefits, provider contracts and correct coding and billing practices. For specific details, please refer to the Medicare Advantage 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 Opticare
Dental services need to be verified by Dental Health & Wellness
Home health services need to be verified by Peach State Health Plan.
Complex imaging, CT, PET, MRA, MRI, and high tech radiology procedures need to be authorized by NIA

All Out of Network requests require prior authorization except emergency care, out-of-area urgent care or out-of-area dialysis.

Are Services being performed in the Emergency Department, or Urgent Care Center or FQHC, or are the services for dialysis or Hospice?

Services being performed in the Emergency Department, or Urgent Care Center or FQHC, or are the services for dialysis or Hospice do NOT require prior authorization

Types of Services YES NO
Is the member being admitted to an inpatient facility?
Are services other than lab, radiology, domiciliary visits or DME being rendered in the home?
Are anesthesia services being requested for pain management or dental surgery?
This service requires prior authorization.
Login Here to submit authorization

Enter the code of the service you would like to check: