Medicare Pre-Auth
DISCLAIMER: 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 upon eligibility, covered benefits, provider contracts and correct coding and billing practices. For specific details, please refer to the Medicare Advantage provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
The following services need to be verified by Evolent.
Complex imaging, MRA, MRI, PET, and CT scan
Musculoskeletal services
Oncology/supportive drugs for members age 18 and older needs to be verified by New Century Health.
Cardiac Services need to be verified by Turning Point
Integrated post-acute care managementservices need to be verified by Tango & Wellsky
Tango and Wellsky are delegated for Skilled Home Health and Post-Acute Facilicy (SNF, IRF, LTACH) management services for Wellare by Allwell HMO members. Please direct all PAC facility authorizations to Wellsky and all Home Health authorizations to tango. Learn more here.
All Out of Network requests require prior authorization except emergency care, out-of-area urgent care or out-of-area dialysis.
Prior Authorization at a Glance
Prior Authorization is NOT Required
The following services do NOT require prior authorization:
- Services rendered in an emergency room or urgent care center
- Services rendered by a public health or welfare agency
- Family planning services billed with a contraceptive management diagnosis
Prior Authorization IS Required
The following services REQUIRE prior authorization:
- Services rendered by an out out-of-network provider, with the exception of emergency and urgent care services
- Admission of a member to an inpatient facility
- Hospice services
- Anesthesia services for pain management or dental procedures.
- Services rendered at home, other than DME, orthotics, prosthetics, supplies and therapeutic injections
- Services rendered by a chiropractor
Prior Authorization Check
To submit a prior authorization Login Here