Navigating the complexities of healthcare administration can be challenging, especially when it comes to ensuring timely patient care and smooth claim processing. For healthcare providers working with AZ Complete Care, understanding the pre-authorization process is crucial. This guide focuses on the AZ Complete Care Pre-Auth Check Tool, your essential resource for verifying service authorization requirements efficiently. Utilizing this tool correctly can streamline your administrative tasks and help ensure appropriate reimbursement for the services you provide. Remember, while this tool is designed to provide the most current information, obtaining pre-authorization does not guarantee claim payment. Payment is contingent upon member eligibility, covered benefits, provider contracts, accurate coding, and compliant billing practices. For detailed information, please consult the provider manual. If you are unsure whether pre-authorization is needed, it is always recommended to submit a request to receive a definitive response. It’s important to note that all new, re-sequenced, and unlisted codes (miscellaneous codes) necessitate prior authorization, regardless of the service location.
Streamlining Service Verification with AZ Complete Care’s Pre-Auth Tool
The AZ Complete Care Pre-Auth Check Tool is designed to simplify the verification process for various healthcare services. Before initiating any services, especially those that are not emergent, leveraging this tool can save valuable time and resources. It helps determine whether a specific service requires pre-authorization, ensuring compliance with AZ Complete Care guidelines and facilitating a smoother claims process.
Certain types of services under AZ Complete Care are managed by specialized external providers. To ensure accurate verification and avoid processing delays, please direct your inquiries to the following entities for these specific service categories:
- Vision Services: For all vision-related services, please verify directly with Centene Vision Services.
- Dental Services: For all dental-related services, please verify directly with Centene Dental Services.
- Complex Imaging (MRA, MRI, PET & CT scans): Verification for these services is managed by Evolent.
- Medical and Radiation Oncology / Biopharmacy drugs: Please direct your verification requests for these services to Evolent.
- Musculoskeletal Services (shoulder, hip, spine, and knee surgery): For pre-authorization related to these surgeries, please contact Turning Point.
- Chiropractic Services: These services are managed by ASH.
It is also crucial to remember that services provided by out-of-network providers are generally not covered by AZ Complete Care unless prior authorization has been obtained. If you are an out-of-network provider interested in joining the AZ Complete Care network, you can find more information and application details at Join Our Network.
Understanding Emergency Department Service Protocols
Services performed in the Emergency Department (ED) or for emergent transportation are handled differently. Crucially, services delivered in the Emergency Department or for Emergent Transportation DO NOT require prior authorization. This exception is in place to ensure immediate and necessary medical attention can be provided in emergency situations without administrative delays.
Key Service Scenarios Requiring Pre-Authorization
While the Pre-Auth Check Tool is the most reliable method for service-specific verification, understanding general scenarios that typically require pre-authorization is helpful. Consider these questions to guide your initial assessment:
| Type of Service | Pre-Authorization Required (YES/NO) |
|---|---|
| Services performed or ordered by a non-participating provider (professionals/facilities)? | YES |
| Member being admitted to an inpatient facility? | YES |
| Anesthesia services rendered for dental surgeries? | YES |
| Oral surgery services provided in an office setting? | YES |
| Member receiving Gender Affirming services? | YES |
If the answer to any of these questions is “YES,” pre-authorization is generally required. However, always use the AZ Complete Care Pre-Auth Check Tool for definitive confirmation.
Utilizing the AZ Complete Care Pre-Auth Check Tool: A Step-by-Step Guide
To effectively use the AZ Complete Care Pre-Auth Check Tool, simply follow these steps:
- Access the Provider Portal: Navigate to the AZ Complete Care provider portal by clicking on the following link: Login Here.
- Login to Your Account: Enter your provider credentials to securely access the portal.
- Locate the Pre-Auth Check Tool: Once logged in, find the “Pre-Auth Check Tool” section, which is typically located in the authorization or resources area of the portal.
- Enter the Service Code: Input the specific CPT code or service code you wish to verify into the designated field within the tool.
By entering the service code, the AZ Complete Care Pre-Auth Check Tool will instantly provide information on whether pre-authorization is required for that specific service under the member’s plan.
Submit Your Prior Authorization Requests
If the Pre-Auth Check Tool indicates that prior authorization is needed, you can conveniently submit your authorization request directly through the provider portal. Simply Login Here and navigate to the authorization submission section to initiate your request.
By utilizing the AZ Complete Care Pre-Auth Check Tool and provider portal, you can efficiently manage pre-authorization requirements, ensuring timely care for your patients and a streamlined administrative process for your practice. Remember to always verify service-specific requirements using the tool and refer to the provider manual for comprehensive guidelines.
