PPO Pre-Auth Check
DISCLAIMER:
All attempts are made to provide the most current information on the Pre-Auth Needed Tool. A prior authorization is not a guarantee of payment. Payment may be denied in accordance with Plan’s policies and procedures and applicable law. 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.
- Musculoskeletal Services Need to Be Verified By TurningPoint.
- Dental Services are handled by Your Dental Plan.
- Vision Services are handled by EyeMed.
- High Tech Imaging services are handled by Evolent.
- Radiation Therapy is handled by eviCore healthcare.
- Refer to the Pharmacy auth guidelines to confirm authorization requirements for pharmacy benefit services.
NOTE: A penalty will apply to services where prior authorization is not obtained if found to be medically necessary. Services will be denied if medical necessity is not established.
Are services being performed in the Emergency Department, Urgent Care, for Emergent Transportation or biomarker testing for an insured with advanced or metastatic stage 3 or 4 cancer?
| Types of Services | YES | NO |
|---|---|---|
| Is the member being admitted to an inpatient facility? | ||
| Is the member being treated for TMJ? | ||
| Is the member taking part in a clinical trial? | ||
| Are services for gender reassignment? |