Medicare Pre-Auth
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.
Home health services need to be verified by Western Sky Community Health Plan.
Complex imaging, CT, PET, MRA, MRI, and high tech radiology procedures need to be authorized by NIA
Musculoskeletal and Cardiac services need to be verified by TurningPoint.
All Out of Network requests require prior authorization except emergency care, out-of-area urgent care or out-of-area dialysis.
Are Services being performed in the Emergency Department, or Urgent Care Center, or are the services for dialysis or Hospice?
| Types of Services | YES | NO |
|---|---|---|
| Is the member being admitted to an inpatient facility? | ||
| Are anesthesia services being requested for pain management, dental surgery or services in the office rendered by a non-participating provider? | ||
| Is this an HMO Out of Network service request? |