The Ambetter Absolute Total Care Prior Authorization Tool helps healthcare providers determine if prior authorization is needed for specific services. While this tool is designed to provide up-to-date information, a prior authorization doesn’t guarantee payment. Claim payment depends on factors like member eligibility, benefits, provider contracts, and accurate coding. Always refer to the provider manual for detailed information. If unsure, submitting a prior authorization request is recommended.
Understanding Ambetter’s Prior Authorization Requirements
Different service types require authorization from specific entities within the Ambetter Absolute Total Care network. Here’s a breakdown:
- Vision Services: Centene Vision Services (https://www.centenevision.com/)
- Dental Services: Centene Dental Services (https://www.centenedental.com/)
- Behavioral Health/Substance Abuse: Ambetter from Absolute Total Care
- Speech, Occupational, and Physical Therapy; Complex Imaging (MRA, MRI, PET, CT scans); Left Heart Catheterization; Implantable Services; Musculoskeletal Surgeries (shoulder, hip, spine, knee); Pain Management; Spinal Cord Stimulators: Evolent (https://www1.radmd.com/). Note: Chiropractic services are not managed by Evolent.
- Medical and Radiation Oncology; Biopharmacy drugs (for members 18+): Evolent (https://my.newcenturyhealth.com/)
- Post-acute Facility Services (SNF, IRF, LTAC): CareCentrix (Fax: 877-250-5290)
Services from out-of-network providers generally require prior authorization. Join the Ambetter network for smoother processing: https://ambetter.absolutetotalcare.com/join-ambetter/become-a-provider.html. Keep in mind that a denied authorization will lead to denied claims.
Emergency Department Services
Prior authorization is not required for services performed in the emergency department.
When is Prior Authorization Required?
Certain non-emergency situations necessitate prior authorization. Use the following table as a guide:
| Service Type | Requires Prior Authorization? |
|---|---|
| Services by Non-Participating Providers | Potentially |
| Inpatient Admission | Potentially |
| Anesthesia for Dental Surgeries | Potentially |
| In-Office Oral Surgery | Potentially |
| Gender Affirming Services | Potentially |
If prior authorization is required, submit your request through the Ambetter provider portal: https://provider.absolutetotalcare.com. You can also use the portal to check if a specific service code requires prior authorization.
Using the Ambetter Absolute Total Care Prior Authorization Tool
To determine if a specific service requires prior authorization, enter the service code into the tool on the provider portal: https://provider.absolutetotalcare.com. This streamlined process allows for quick verification, contributing to efficient claim processing. Remember that this tool is an aid, and consulting the provider manual for comprehensive information remains crucial.
