Provider Toolkit: Prior Authorization Guide

How to Secure Prior Authorization

Pre-Auth Needed Tool

Use the Pre-Auth Needed Tool on Ambetter.HomeStateHealth.com to quickly determine if a service or procedure requires prior authorization.

Submit Prior Authorization

If a service requires authorization, submit via one of the following ways:


SECURE WEB PORTAL
Provider.HomeStateHealth.com
As of 1/1/2021 all Prior Authorizations should be submitted through the Secure Web Portal. This is the required and fastest method.


PHONE
1-855-650-3789
After normal business hours and on holidays, calls are directed to the plan’s 24-hour nurse advice line. Notification of authorization will be returned by phone, fax or web.


FAX
Medical and Behavioral Health
1-855-690-5433

See below for a list of services that require prior authorization.

 

Please note:

  1. Emergency services DO NOT require prior authorization.
  2. All out-of-network services and providers DO require prior authorization.
  3. Failure to complete the required authorization or notification may result in a denied claim.
  4. Failure to obtain a prior authorization for any code(s) on the claim that required prior authorization, will result in a denial of the entire claim.
  5. If additional procedures are performed during the procedure, the provider must contact the health plan to update the authorization within 72 hours of the procedure in order to avoid a claim denial.
  6. Ambetter will update authorizations but will not retro-authorize services.

Services and Procedures Requiring Prior Authorization

THE FOLLOWING LIST IS NOT ALL-INCLUSIVE

Ancillary Services

Procedures/Services

Inpatient Admissions

  • Air ambulance transport (non-emergent fixed wing airplane)
  • Durable Medical Equipment (DME)
  • Home healthcare services
  • Hospice
  • Furnished medical supplies
  • Orthotics/prosthetics
  • Genetic testing
  • Quantitative urine drug screen
  • Reconstructive surgery
  • Experimental or investigational
  • High Tech Imaging administered by NIA (CT, MRI, PET):
    • Submit requests to RadMD.com
  • Pain management
  • Cardiac and respiratory therapy
  • All inpatient admissions (within 1 business day of admission)
  • Observation stays exceeding 48 hours 
    • Notification is required within 1 business day if admitted
  • Transplants (not including evaluations)
  • Urgent/emergent admissions
  • Partial inpatient, PRTF and/or intensive outpatient programs

All elective/scheduled admission notifications requested at least 5 days prior to the scheduled date of admit including but not limited to:

  • Medical admissions
  • Surgical admissions
  • Hospice care
  • Rehabilitation facilities


LOG INTO OUR SECURE WEB PORTAL

Provider.HomeStateHealth.com