Ambetter from PA Health & Wellness (Commercial/Exchange)
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.
Behavioral Health services need to be verified by Ambetter from Pennsylvania Health and Wellness.
**NOTICE: Effective 11-1-2020, Musculoskeletal Surgical Services Need to Be Verified by TurningPoint. Please contact TurningPoint by phone at 855-909-8222 or by fax at 717-303-5072.
NOTE: Services related to an authorization denial will result in denail of all associated claims.
Are services being performed in the Emergency Department, or for Emergent Transportation?
|Types of Services||YES||NO|
|Are services being performed or ordered by a non-participating provider?|
|Is the member being admitted to an inpatient facility?|
|Are anesthesia services being rendered for pain management or dental surgeries?|
|Is the member receiving hospice services?|
|Is the member receiving gender reassignment services?|
|Are services being rendered in the home excluding sleep studies, DME, medical equipment supplies, orthotics and prosthetics?|