Medicaid Pre-Auth
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 need to be verified by Envolve Vision.
Dental Services need to be verified by Envolve Dental.
Complex imaging, MRA, MRI, PET, and CT scans need to be verified by NIA
Non-participating providers must submit Prior Authorization for all services.
For non-participating providers, Join Our Network.
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.
Are Services being performed in the Emergency Department or Urgent Care Center or Family Planning services billed with a Contraceptive Management diagnosis?
| Types of Services | YES | NO |
|---|---|---|
| Is the member being admitted to an inpatient facility? | ||
| Are services being rendered for pain management? | ||
| Are anesthesia services being rendered for dental procedures? | ||
| Are oral surgery services being provided in the office? | ||
| Are services, other than DME, orthotics, prosthetics, and supplies, being rendered in the home? | ||
| Is the member receiving hospice services? | ||
| Are services being rendered in a Residential Substance Abuse Treatment Facility? |