Pre-Auth Check | Ambetter from Magnolia Health


Pre-Auth Needed?

Effective October 12, 2020, we are no longer sending hard copy or paper notifications for authorization approvals. Hard copies of denial letters will still be mailed to both provider and member. Approvals and denials will be available in real time in our secure provider portal.

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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 on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.

Vision services, including all services rendered by an Optician, Ophthalmologist or Optometrist need to be verified by Envolve Vision

Dental services need to be verified by Envolve Dental

Behavioral Health/Substance Abuse need to be verified by Magnolia

The following services (identifiable by procedure code search) need to be verified by Evolent:  Complex Imaging, MRA, MRI, PET, and CT scans; Left Heart Catheterization & Implantable services; Speech, Occupational and Physical Therapy services (excluding chiropractor specialty providers – no authorization required).  Effective for dates of service 3/1/2024 forward:  Pain Management and Spinal Cord Stimulators; Musculoskeletal services for the spine, shoulder, hip, and knee.

Musculoskeletal services for dates of service prior to 3/1/2024 will continue to be verified by TurningPoint

Oncology Biopharmacy and Radiation Oncology drugs need to be verified by New Century Health.

Post-acute facility (SNF, IRF, and LTAC) prior authorizations need to be verified by CareCentrix; Fax 877-250-5290

Services provided by Out-of-Network providers are not covered by the plan. Join Our Network

Note: Services related to an authorization denial will result in denial of all associated claims.


Are Services being performed in the Emergency Department?

Types of Services YES NO
Are the services being performed or ordered by a non-participating provider (professionals/facilities)?
Is the member being admitted to an inpatient facility?
Are anesthesia services being rendered for dental surgeries?
Are oral surgery services being provided in the office?
Is the member receiving Gender Reassignment services?