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Medicaid Pre-Auth

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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 Medicaid Provider Manual. If you are uncertian that prior authorization is needed, please submit a request for an accurate response.

Prior authorization for medications will not be accepted through the web portal.

For specialty medications given in an outpatient setting, please submit a specialty drug prior authorization form.

Vision Services need to be verified by OptiCare.

Dental services for members under 21 need to be verified by SCDHHS through the EPSDT program.

As of January 1, 2015, Home Health and Durable Medical Equipment will need to be submitted to Absolute Total Care

Complex Imaging , MRA, MRI, PET, and CT Scans need to be verified by NIA.

Behavioral Health/Substance Abuse need to be verified by Cenpatico.

For non-participating providers, Join Our Network.

Prior authorization is required for all non-emergent services provided by non-contracted, out-of-state providers.

Are Services being performed in the Emergency Department, or Urgent Care Center, or Public Health or Public Welfare Agency, or Family Planning services billed with contraceptive management diagnosis?

Types of Services YES NO
Is the member being admitted to an inpatient facility?
Are services, other than DME, orthotics, prosthetics, and supplies, being rendered in the home?
Are services being rendered by a podiatrist?
Are anesthesia services being rendered for pain management?