Medicaid Pre-Auth
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.
We have separate fax numbers for Medicaid and Medicare pre-authorizations. Please make sure you use the correct fax number to expedite your request.
Medicaid Fax (Physical/Medical): 1-866-467-1316
Medicaid Fax (Behavioral Health Outpatient): 1-833-522-2807
Medicaid Fax (Behavioral Health Inpatient): 1-833-522-2806
Please see section below for Behavioral Health pre-authorization forms.
- Behavioral Health/Substance Abuse authorization requests:
- Inpatient psych and detox auth requests: 1-800-589-3186 to complete live reviews
- Behavioral Health Outpatient Treatment Form (PDF)
- Behavioral Health Inpatient Treatment Form (PDF)
- Psychological Testing Form (PDF)
- Behavioral Health Authorization Appeals Fax: 1-866-714-7991
- Vision services need to be verified by Envolve Vision
- Dental Services need to be verified by Envolve Dental
- Prior Authorization for all services except hospital admissions and behavioral health treatment requests, use these forms:
- Prior Authorization Form - Outpatient Services (PDF).
- Prior Authorization Form - Outpatient Continuation Form (PDF) This form is optional and meant to be used when a request exceeds more than four (4) Procedure Codes.
- Prior authorization is required for hyaluronate derivatives under the medical benefit.
- Prescriptions and pharmaceuticals need to be verified by Medicaid FFS. The Preferred Drug List (PDL) is located on the ForwardHealth website.
Step-Therapy
In some cases, it is required that our members first try a certain medication to treat their medical condition before another medication is covered. For example, Medication A and Medication B both treat the member's medical condition. Medication B may not be covered unless the member tries Medication A first. If Medication A does not work for our member, Medication B will be covered.
Use the form below to check if preauthorization is required. Print a copy of your results for your records.
Are services being performed in the Emergency Department or an Urgent Care Center, or are they Family Planning Services billed with a contraceptive management diagnosis?
| Types of Services | YES | NO |
|---|---|---|
| Is the member being admitted to an inpatient facility? | ||
| Are anesthesia services being rendered for pain management? | ||
| Are services being rendered in the home other than H0004, DME, orthotics, prosthetics, supplies, sleep studies, or 99381-99387, 99391-99397, 90476-90748 if rendered by a PCP or health department? | ||
| Are podiatry services being rendered after the 3rd visit in a year? | ||
| Is a scar revision diagnosis being billed? |