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NOTICE OF DATA BREACH

We are sorry to tell you about a privacy event that impacted our vendor, Episource, LLC (“Episource” or “They”). Episource works with health plans, including Peach State Health Plan. This event may have involved your data. Click here to learn more about the data breach.
 

Medicaid Pre-Auth

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, 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 Services

Dental services, (D0000-D9999), need to be verified by Envolve Dental

Musculoskeletal, Complex Imaging, MRA, MRI, PET, CT Scans, High Tech Radiology and Cardiac need to be verified by Evolent

ENT and Cardiac Services need to be verified by TurningPoint

Behavioral Health/Substance Abuse need to be verified by Peach State Health Plan.

Non-participating providers must submit prior authorization for all services.

For non-participating providers, Join Our Network

Prior Authorization at a Glance

Prior Authorization is NOT Required

The following services do NOT require prior authorization:

  • Services rendered in an emergency room or urgent care center
  • Services rendered by a public health or welfare agency
  • Family planning services billed with a contraceptive management diagnosis

Prior Authorization IS Required

The following services REQUIRE prior authorization:

  • Services rendered by an out out-of-network provider, with the exception of emergency and urgent care services
  • Admission of a member to an inpatient facility
  • Hospice services
  • Anesthesia services for pain management or dental procedures.
  • Services rendered at home, other than DME, orthotics, prosthetics, supplies and therapeutic injections
  • Services rendered by a chiropractor

Prior Authorization Check

To submit a prior authorization Login Here

CMS Interoperability & Prior Authorization Final Rule: CY2025 Prior Authorization Requirements Reports and Metrics Summaries

In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS 0057 F), we are annually publishing our prior authorization requirements and performance metrics to promote transparency, accountability, and better support our members and providers.

Reports:

The data presented in these publications reflects prior authorization requests processed during the applicable measurement year in accordance with CMS reporting specifications. Metrics are calculated using CMS defined methodologies and may not be directly comparable to alternative reports or third party summaries.