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.
Please verify Prior Authorization Requirements for Specialty Services with contracted Vendors:
Vision: Envolve Vision
Oncology/supportive drugs and Radiation Oncology
requests need to be verified by Evolent Specialty Services (ESS)
For Pharmacies: Comprehensive Medication Review please visit Outcomes.com
Provider Web Portal
The following services Musculoskeletal Services, PT, ST, OT, Complex Imaging, MRA, MIA, PET and CT Scans: Evolent
Dental services are not administered by NH Healthy Families.
Non-participating providers must submit Prior Authorization for all services. For non-participating providers, Join Our Network.
Urine Drug Screens rendered by MAT (Medication Assisted Treatment) providers require notification only. Prior auth is not required. For all other providers PA is required for this service.
Are Services being performed in the Emergency Department or are these family planning services billed with a contraceptive management diagnosis?
| Types of Services | YES | NO |
|---|---|---|
| Is the member being admitted to an inpatient facility? | ||
| Is the member having an observation stay exceeding 24 hours? | ||
| Are services, other than DME, orthotics, prosthetics, and supplies, and PT/OT/ST evaluations being rendered in the home? | ||
| Is the member receiving hospice services? | ||
| Are anesthesia services being rendered for pain management or dental surgery? |