For the best experience, please use the Pre-Auth tool in Chrome, Firefox, or Internet Explorer 10 and above.
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.
Please refer the Prior Auth Quick Reference Guide (PDF) for questions.
PLEASE NOTE: The display for therapy services (PT/ST/OT) is incorrect. Prior Authorization is only required for non-participating providers.
A number of codes are incorrectly showing as non-covered benefits. These codes are covered for Integrated Managed Care (IMC) members and Behavioral Health Services Only (BHSO) members. Please see the following corrected PA tool responses. We hope to have the PA tool responses corrected as soon as possible.
H0034 No PA required for any providers
H0036 No PA required for any providers
H0045 Authorization is required for non-participating providers only.
H2012 PA required for all providers
S9125 Authorization is required for non-participating providers only.
S9485 No PA for all providers
T1005 Authorization is required for non-participating providers only.
T1009 No PA required for any providers
T1013 No PA required for any providers
Vision Services need to be verified by Envolve Vision.
Dental Services need to be verified by DSHS.
Complex imaging, MRA, MRI, PET, and CT scans need to be verified by NIA.
Behavioral Health/Substance Abuse requests can be submitted using our web portal or by fax, using an OTR form (PDF).
For non-participating providers, Join Our Network.
Are services being performed in the emergency department or urgent care center or are these family planning services billed with a contraceptive management diagnosis?
|Types of Services||YES||NO|
|Is the member being admitted to an inpatient facility?|
|Are professional services being rendered in the home? (professional services do not include the delivery of DME, orthotics, prosthetics, or supplies).|
|Are anesthesia being rendered for pain management or dental surgery?|
|Are oral surgeon services being rendered in office?|