Medicaid Pre-Auth

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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 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.

 

Utilization Management Reviews ensure our members get the right care, at the right time, in the right setting. Prior authorization is required before certain services are rendered to confirm medical necessity as defined by the member’s plan.

 

Use the Meridian tool to see if a pre-authorization is needed. If an authorization is needed, you can access our login to submit online. Please note some pre-service reviews are supported by Meridian Vendor partners. For a list of applicable services and supporting vendors, see the Vendor Solutions table below.

 

All Out of Network requests require prior authorization except emergency care, transportation, out-of-area urgent care or out-of-area dialysis and codes that state “No authorization required”. For non-participating providers, Join Our Network.

 

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

Types of Services YES NO
Is the member being admitted to an inpatient facility?
Are chiropractic services being rendered after the 12th visit?
Are services other than DME, orthotics, prosthetics and supplies being provided in the home?
Are hospice services being provided?

For the best experience, please use the Pre-Auth tool in Chrome, Firefox, or Internet Explorer 10 and above.

Vendor Solutions Vendor Links
MRA, MRI, PET, CT Scans, Cardiac Imaging, Pain Management, Speech, Occupational and Physical Therapy NIA
Musculoskeletal Services Turning Point
Non-Emergent Non-Ambulance Transportation MTM
Oncology/Supportive Drugs for Members Age 18 and Older New Century Health

Other Supporting Documentation

Utilization Management Report 2023 (PDF)

Inpatient Medicaid Prior Authorization Form (PDF)

Outpatient Medicaid Prior Authorization Form (PDF)

PA Codes List (Excel)