HAVE AN ENROLLMENT NEED? SHOP OUR PLANS
Provider Toolkit: Prior Authorization Guide
How to Secure Prior Authorization
Pre-Auth Needed Tool
Use the Pre-Auth Needed Tool on Ambetter.LouisianaHealthConnect.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 Prior Authorization Fax: 833-603-2871
- Medical Inpatient Admissions Fax: 833-751-2724
- Medical Concurrent Review Fax: 833-751-2721
- Behavioral Health Inpatient Fax: 833-792-2721
- Better Health Outpatient Fax: 833-792-2720
- High Tech Imaging: RadMD.com
- Rehabilitation Services and Pain Management: RadMD.com
- Pharmacy - Envolve Pharmacy Solutions prior authorization can be accessed at https://pharmacy.envolvehealth.com/pharmacists.html under the "CoverMyMeds" link
Timeframes for Prior Authorization Requests and Notifications
The following timeframes are required of the ordering provider for prior authorization and notification:
|Schedule admissions||5 business days prior|
|Elective outpatient services||5 business days prior|
|Emergent inpatient admissions||1 business day|
|Observation - 48 hours or less||1 business day for non-participating providers|
|Observation - greater than 48 hours||1 business day|
|Maternity admissions||1 business day|
|Newborn admissions||1 business day|
|Neonatal Intensive Care Unit (NICU) admissions||1 business day|
|Outpatient Dialysis||1 business day|
|Organ transplant initial evaluation||30 days prior|
|Clinical trials services||30 days prior|
- 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
- Outpatient Physical, SPeech and Occupational therapy administered by NIA*
- Experimental or investigational
- High Tech Imaging administered by NIA
- Cardiac and respiratory therapy
- Observation stays exceeding 48 hours
- Notification is required within 1 business day if admitted
- Partial inpatient, PRTF and/or intensive outpatient programs
*Effective for dates of service on or after January 1, 2022
All out-of-network services and providers require prior authorization, excluding emergency services.