Medicaid Pre-Auth
DISCLAIMER: 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.
Prior Authorization at a Glance
Prior Authorization is NOT Required
The following services do NOT require prior authorization:
- Services rendered in an emergency room or urgent care center
- Services rendered by a public health or welfare agency
- Family planning services billed with a contraceptive management diagnosis
Prior Authorization IS Required
The following services REQUIRE prior authorization:
- Services rendered by an out out-of-network provider, with the exception of emergency and urgent care services
- Admission of a member to an inpatient facility
- Hospice services
- Anesthesia services for pain management or dental procedures.
- Services rendered at home, other than DME, orthotics, prosthetics, supplies and therapeutic injections
- Services rendered by a chiropractor
Prior Authorization Check
To submit a prior authorization Login Here