Prior authorization requirements

Please verify benefit coverage prior to rendering services. Inpatient services and non-participating providers always require prior authorization.

Services billed with the following revenue codes ALWAYS require prior authorization:

  • Elective services provided by or arranged at nonparticipating facilities.
  • All services billed with the following revenue codes:
0023
 Home health prospective payment system
0240–0249
 All-inclusive ancillary psychiatric
0570–0572, 0579
 Home health aide
0632
 Pharmacy multiple sources
0901, 0905-0907, 0913, 0917
 Behavioral health treatment services
0944-0945
 Other therapeutic services
0961
 Psychiatric professional fees
3101-3109
 Adult day and foster care

Behavioral health

Fax all requests for services that require prior authorization to:

Inpatient:

1-844-430-1702

Outpatient:

1-844-430-1703

Pharmacy

Check the latest Formulary for the members’ service area on our Benefits and pharmacy page.

Prior authorization code look-up

Please note:

  1. This tool is for outpatient services only.
  2. Inpatient services and non-participating providers always require prior authorization.
  3. This tool does not reflect benefits coverage,* nor does it include an exhaustive listing of all non-covered services (for example, experimental procedures, cosmetic surgery, etc.). Refer to your provider manual for coverage/limitations.

Note: Services may be listed as requiring prior authorization that may not be covered benefits for a particular member. Please verify benefit coverage prior to rendering services.

To determine coverage of a particular service or procedure for a specific member:

  • Access eligibility and benefits information on the Availity Portal
  • Use the Prior Authorization Lookup Tool accessed through Payer Spaces in Availity
  • Call Provider Services at 1-866-805-4589 for Medicare Advantage

Provider tools and resources

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