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Medicaid Prior Authorization Tool

DISCLAIMER: All attempts are made to provide the most current information on the Medicaid Prior Authorization 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.

The following services need to be verified by Evolent: Complex Imaging, MRA, MRI, PET & CT scans, Left Heart Cath and Implantables, Pain Management, and Spinal Cord Stimulators

All services rendered by non-participating providers require prior authorization.

Non-participating providers interested in participation may apply by visiting the Join Our Network page.

Per DE Title 18 Insurance Code Health Insurance Contracts, prior authorization is not required for medically necessary inpatient treatment of drug and alcohol dependencies. However, notification is required within 48 hours of admission – please utilize the SUD Notification of Admission form to notify DFH timely.

 

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 online, providers may use Availity Essentials or the Secure Provider Portal (Legacy), which also offer support for routine tasks.