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Prior Authorization

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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.  

Non-Emergent Non-Ambulance Transportation needs to be verified by MTM.

MRA, MRI, PET Scans, Cardiac, Imaging and Therapy, MSK and IPM must be verified by Evolent.


All Out of Network requests require prior authorization except emergency care, out-of-area urgent care, or out-of-area dialysis.

For non-participating providers, Join Our Network.

LTTS Providers - Please contact the Health Plan for authorization requirements.


Are services being performed in the Emergency Department or Urgent Care Center or for Dialysis or 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 requested for pain management?
Is a non-par provider rendering services other than flu/pneumonia shots?