Prior Authorization
Please note, failure to obtain authorization may result in administrative claim denials. Absolute Total Care providers are contractually prohibited from holding any member financially liable for any service administratively denied by Absolute Total Care for the failure of the provider to obtain timely authorization.
Check to see if a pre-authorization is necessary by using our Pre-Auth Check Tool.
If an authorization is needed, you can log into your account to submit one online or fill out the appropriate fax form on the Provider Manuals and Forms page.
As the Medical Home, primary care providers (PCPs) should coordinate all healthcare services for Absolute Total Care members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. All out of network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.
Some services require prior authorization from Absolute Total Care in order for reimbursement to be issued to the provider. See our Prior Authorization List, which will be posted soon, or use our Pre-Auth Check Tool.
Standard prior authorization requests should be submitted for medical necessity review at least 10 calendar days before the scheduled service delivery date or as soon as the need for service is identified.
Urgent requests will be reviewed within 72 hours from the time the request has been received.
Non-urgent requests will be reviewed within 14 calendar days from the time the request has been received.
Absolute Total Care’s Medical Management Department hours of operation are 8 a.m. to 6 p.m. (EST), Monday through Friday (excluding holidays). After normal business hours, NurseWise staff is available to answer questions and intake requests for prior authorization.
Emergent and post-stabilization services do not require prior authorization.
Urgent/emergent admissions require notification within one (1) business day following the admit date.
We will process most routine authorizations within five (5) business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email or secure web portal.