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Provider Toolkit: Prior Authorization Guide
How to Secure Prior Authorization
Pre-Auth Needed Tool
Use the Pre-Auth Needed Tool on AmbetterofNorthCarolina.com to quickly determine if a service or procedure requires prior authorization.
Submit Prior Authorization
If a service requires authorization, submit via one of the following ways:
After normal business hours and on holidays, calls are directed to the plan’s 24-hour nurse advice line. Notification of authorization will be returned by phone, fax or web.
Medical and Behavioral Health
- Emergency services DO NOT require prior authorization.
- All out-of-network services and providers DO require prior authorization.
- Failure to complete the required authorization or notification may result in a denied claim.
Services and Procedures Requiring Prior Authorization
THE FOLLOWING LIST IS NOT ALL-INCLUSIVE
- Air ambulance transport (non-emergent fixed wing airplane)
- Durable Medical Equipment (DME)
- Home healthcare services
- Furnished medical supplies
- Genetic testing
- Quantitative urine drug screen
- Reconstructive surgery
- Experimental or investigational
- High Tech Imaging (CT, MRI, PET) and Therapy (PT, OT, ST) administered by NIA:
- Submit requests to RadMD.com
- Pain management
- Cardiac and respiratory therapy
- All inpatient admissions (within 1 business day of admission)
- Observation stays exceeding 48 hours
- Notification is required within 1 business day if admitted
- Transplants (not including evaluations)
- Urgent/emergent admissions
- Partial inpatient, PRTF and/or intensive outpatient programs
All elective/scheduled admission notifications requested at least 5 days prior to the scheduled date of admit including but not limited to:
- Medical admissions
- Surgical admissions
- Hospice care
- Rehabilitation facilities