Medicare 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 upon eligibility, covered benefits, provider contracts and correct coding and billing practices. For specific details, please refer to the Medicare Advantage provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
The following services need to be verified by Evolent.
Complex imaging, MRA, MRI, PET, and CT scan
Musculoskeletal services
Oncology/supportive drugs for members age 18 and older needs to be verified by New Century Health.
Cardiac Services need to be verified by Turning Point
Integrated post-acute care managementservices need to be verified by Tango & Wellsky
Important Reminder- Effective October 1, 2025, Tango and Wellsky will be delegated for Skilled Home Health and Post-Acute Facility management services for Wellcare Medicare Advantage members. Please direct Home Health authorization to Tango and PAC authorizations to Wellsky beginning October 1, 2025.
All Out of Network requests require prior authorization except emergency care, out-of-area urgent care or out-of-area dialysis.
Are Services being performed in the Emergency Department, or Urgent Care Center, or are the services for dialysis or Hospice?
| Types of Services | YES | NO |
|---|---|---|
| Is the member being admitted to an inpatient facility? | ||
| Are anesthesia services being requested for pain management, dental surgery or services in the office rendered by a non-participating provider? | ||
| Is this an HMO Out of Network service request? |