Navigating the complexities of healthcare administration can be challenging, especially when it comes to understanding pre-authorization requirements. For providers working with Ambetter from Absolute Total Care, utilizing the right tools and resources is crucial for efficient claims processing and ensuring patients receive timely care. This guide offers a comprehensive overview of the pre-authorization process and the essential provider tools available to streamline your workflow.
Understanding Service Verification for Ambetter from Absolute Total Care
Different types of services require verification through specific channels when dealing with Ambetter from Absolute Total Care. It’s important to direct your inquiries to the correct entity to avoid delays and ensure accurate information.
- Vision Services: For vision service verification, please contact Centene Vision Services.
- Dental Services: Dental service verification is handled by Centene Dental Services.
- Behavioral Health/Substance Abuse Services: Verification for these services is managed directly by Ambetter from Absolute Total Care.
Certain medical services are managed through Evolent for pre-authorization:
- Evolent (https://www1.radmd.com/): This includes Speech, Occupational, and Physical Therapy; Complex Imaging (MRA, MRI, PET & CT scans); Left Heart Catheterization & Implantable services; Musculoskeletal services for shoulder, hip, spine, and knee surgery; Pain Management, and Spinal Cord Stimulators. Note: Chiropractic specialty providers are not managed by Evolent.
- Evolent (https://my.newcenturyhealth.com/): Medical and Radiation Oncology / Biopharmacy drugs for members aged 18 and older are verified through this Evolent portal.
For post-acute care facility services, verification is managed by CareCentrix:
- CareCentrix: This includes services in Skilled Nursing Facilities (SNF), Inpatient Rehabilitation Facilities (IRF), and Long-Term Acute Care hospitals (LTAC). Fax your verification requests to 877-250-5290.
It’s critical to remember that services from out-of-network providers are generally not covered without prior authorization. If you are an out-of-network provider and wish to join the Ambetter network, you can find more information at Join Our Network.
Important Disclaimer: While every effort is made to ensure the Pre-Auth Needed Tool provides the most up-to-date information, pre-authorization does not guarantee claim payment. Payment is contingent upon member eligibility, covered benefits, provider contracts, and accurate coding and billing practices. Always consult the provider manual for detailed guidelines. When in doubt about whether prior authorization is required, submitting a request is recommended to ensure accuracy. NOTE: Services linked to an authorization denial will also result in claim denials.
Emergency Department Services: No Pre-Authorization Needed
Services performed in the Emergency Department (ED) do not require prior authorization. This ensures that patients receive immediate and necessary care in emergency situations without administrative delays.
Determining When Prior Authorization is Needed
To clarify when prior authorization is necessary, consider the following questions:
| Service Scenario | Prior Authorization Required? |
|---|---|
| Services performed or ordered by a non-participating (out-of-network) provider? | YES |
| Member admission to an inpatient facility? | YES |
| Anesthesia services for dental surgeries? | YES |
| Oral surgery services provided in an office setting? | YES |
| Member receiving gender affirming services? | YES |
If you answered “YES” to any of these questions, prior authorization is required.
Submitting a Prior Authorization Request
The primary tool for Ambetter from Absolute Total Care providers to submit prior authorization requests is the provider portal.
To submit a prior authorization, Login Here.
This portal offers a secure and efficient way to manage your authorization requests and track their status.
Checking Service Codes for Authorization Requirements
If you need to quickly check if a specific service code requires prior authorization, the provider portal offers a convenient tool.
Enter the service code you wish to check:
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This feature allows you to verify authorization needs upfront, streamlining your administrative processes and ensuring compliance.
For all prior authorization submissions, Login Here to access the Ambetter provider portal and utilize the necessary tools. By understanding these guidelines and leveraging the available resources, providers can effectively manage pre-authorization requirements and deliver seamless care to Ambetter from Absolute Total Care members.
