Prior Authorization Requirements for Health Insurance Marketplace (2024)

For some services, utilization review is necessary to determine the medical necessity and appropriateness of a covered health care service for Superior HealthPlan’s managed care members. For those services, utilization review is performed before (prior authorization), during (concurrent review) or after (retrospective review) the service is delivered.

Provider Authorization List

A listing of the Ambetter covered services that require prior authorization may be accessed by visiting:

Health Insurance Marketplace Prior Authorization List (PDF)

Prior Authorization Requirements effective September 1, 2019 and after:

The effective date of prior authorization requirements implemented on or after September 1, 2019 for specific codes can be accessed at the link below:

Marketplace (PDF)

An electronic prior authorization required prescreen tool is available on Ambetter’s website to provide procedure code specific information for the services, supplies, equipment and Clinician Administered Drugs (CAD) that require prior authorization. To view the AmbetterPrior Authorization Prescreen Tool, access the link below:

• Health Insurance Marketplace (Ambetter from Superior HealthPlan)

Prescreen Tools for CHIP/Medicaid and STAR+PLUS MMP/Medicare Programs are also included below:

• Medicaid and CHIP
• STAR+PLUS MMP
• Medicare Advantage

Authorization Forms

To access Authorization Request forms for applicable services, visitthe Medical Management section of the Provider Resources webpage.

Prior Authorization Clinical Documentation Requirements

This listing provides the clinical documentation required to be submitted with authorization requests for prospective, concurrent and retrospective utilization review.

Clinical Documentation Requirements for Health Care Services that Require Authorization (PDF)

Clinical and Clinical Payment Policies

To access Ambetter’s clinical and clinical payment policies, visit

Prior Authorization Denial and Approval Rates

Ambetter pre-authorization approval and denial rates for medical care or health-care services may be accessed by visiting:

• 2023 Prior Authorization Denial and Approval Rates - Ambetter (PDF)

Authorization Process, Procedures and Protocols

Please reference the sections below for additional prior authorization requirements and information.

Emergency And Post Stabilization Services

Physical and behavioral health emergencies, life threatening conditions and post-stabilization services do not require prior authorization.

These include non-elective, inpatient admissions, including those that are subsequent to emergency services and stabilization of the patient, which do not require prior authorization.

All inpatient confinements do require ‘notification’ of the admission no later than the next business day after the date of admission. Following notification of admission, concurrent and/or retrospective utilization review is conducted to confirm the continued medical necessity of the inpatient stay. Facility providers should referenceNotification of Admission and Concurrent Reviewsection on this webpage for additional details and information.

Professional services provided during a medically necessary inpatient admission do not require separate authorization.

Non-Preferred Provider Services

As an Exclusive Provider Benefit Plan (EPBP), Ambetter’s covered benefits do not include non-preferred provider services, with some exceptions. These include emergency services and medically necessary non-preferred provider services that are prior authorized.

Prior authorization is required before the provision of all non-emergent health-care services, supplies, equipment and Clinician Administered Drugs (CAD) delivered by a non-preferred provider.

It is the responsibility of the rendering, ordering or referring practitioner to initiate the request for prior authorization for non-emergency, non-preferred provider health-care services. Those requests will be reviewed to determine the medical necessity of approving the delivery of care outside of Ambetter’s preferred provider network, for those situations in which no preferred provider is available to deliver the applicable service. If a preferred provider is available for provision of the requested service, the prior authorization request may be denied with redirection to a preferred provider.

Timeframe For Requests

Requesting providers must initiate a request for prior authorization for non-urgent health-care services prior to delivering the requested service, medical supply equipment or Clinician Administered Drug (CAD).

It is recommended that prior authorization requests be submitted a minimum of5 business daysbefore the desired start date of service.

Procedures And Requirements

• Fax, Phone, Web Contact Information
  • Prior authorization requests can be submitted by phone, fax or online throughAmbetter’s Secure Provider Portal.
  • Prior authorization assistance for members and providers is available between 6:00 a.m. and 6:00 p.m., Central Time, Monday through Friday on each day that is not a legal holiday and between 9:00 a.m. and noon, Central Time, on Saturday, Sunday, and legal holidays.Contact information for all services that require prior authorization are included below:
    • Prior Authorization Phone Numbers:
      • Physical Health: 1-877-687-1196
      • Behavioral Health: 1-877-687-1196
      • Clinician Administered Drugs (CAD): 1-877-687-1196, ext. 22272
      • Prescription Drugs: 1-866-399-0928
      • Radiology and Cardiac Imaging: 1-877-687-1196
      • Musculoskeletal Surgical Procedures: 1-855-336-4391
    • Prior Authorization Fax Numbers:
      • Physical Health: 1-855-537-3447
      • Behavioral Health: 1-844-307-4442
      • Clinician Administered Drugs (CAD): 1-866-562-8989
      • Prescription Drugs: 1-866-399-0929
      • Radiology and Cardiac Imaging: 1-800-784-6864
      • Musculoskeletal Surgical Procedures: 1-833-409-5393
    • Prior Authorization Secure Web Portals:
      • Physical Health
      • Behavioral Health
      • Clinician Administered Drugs
      • Prescription Drugs
      • Radiology and Cardiac Imaging
      • Musculoskeletal Surgical Procedures
• Demographic and Clinical Information
  • To ensure that the medical necessity review of a prior authorization request can be timely processed for determination, the following information must be included with each prior authorization request:
    • Member information (member name, member DOB, member Ambetter ID number); and
    • Provider information (Rendering provider name, NPI, TIN); and
    • Priovider signature/Provider order; and
    • Specification and description of service, supply, equipment, or Clinician-Administered Drugs (CAD) procedural/service code(s) and description (CPT, HCPC, NDC); and
    • Pertinent diagnosis/conditions that relate to the need for the service (ICD-10); and
    • Objective clinical information necessary to support medical necessity for the requested service; and
    • Start and end date(s) of service; and
    • Frequency and duration
  • Depending on the request, specific clinical documentation and information may also be required to complete the medical necessity review.
• Screening Criteria
  • Utilization review decisions are made in accordance with generally-accepted clinical practices, taking into account the special circ*mstances of each case that may require an exception to the standard. Clinical screening criteria are used for the review of medical necessity of the requested service. If the medical necessity of a prior authorization cannot be confirmed by clinical staff, a Texas licensed provider/medical director reviews the case, and includes the opportunity for a peer discussion with the rendering/ordering provider prior to issuing any adverse determination.
  • At least annually, an assessment is completed to validate the consistency clinical reviewers apply clinical criteria in case reviews. Ambetter does not financially incentivize providers or other individuals in utilization review decision making, and utilization management policy and criteria do not encourage decisions that result in underutilization.
  • The following guidelines are utilized to make medical necessity decisions, on a case-by-case basis, based on the information provided on the member’s health status, as applicable:
    • Federal and State Laws and Rules
    • Interqual® criteria
    • Proprietary clinical guidelines
  • To access clinical policy screening criteria for specific service types, visitAmbetter’s Clinical and Payment Policies webpage.
    
• Phone Requests
  • Prior authorization phone requests require subsequent submission of applicable documentation and clinical information to facilitate the medical necessity review of the request.
  • To access the prior authorization phone numbers for each applicable services type, please review theFax, Phone, Web Contact Informationsection of this webpage underProcedures and Requirements.
• Fax Requests
  • Ambetter encourages providers to include a completed Authorization Request form with all prior authorization requests submitted through Fax.
  • For Authorization Request forms for applicable services, visitAmbetter’s Provider Forms webpage.
  • Applicable clinical documentation and information necessary to review the request must be submitted with all fax authorization requests.
  • To access the prior authorization fax numbers for each applicable services type, please review the Prior Authorization Fax Contact List on this webpage.
• Provider Identifiers
  • When submitting a request for authorization or to provide notification of an inpatient admission by fax, phone, orAmbetter’s Secure Provider Portal, the Tax Identification Number (TIN) and National Provider Identifier (NPI) that will be used to bill the claim after the authorized service is provided must be supplied.
  • It is very important that the NPI and TIN supplied for the authorization request is the same NPI and TIN that will be included on the claim.
  • If the provider identifiers in the authorization do not match the provider identifiers on the claim, the claim may be denied even if the authorization request was approved. Providers are required to appeal the denied claim(s) in this situation.
• Incomplete Requests
  • If a prior authorization request does not include the demographic and/or clinical information necessary to complete the medical necessity review of the request, 2 phone call attempts are completed to obtain the missing documentation/information.
  • If the required clinical information is not received as requested, the prior authorization request is forwarded to a Medical Director for determination, based on the clinical information available.

Outpatient Pharmacy Requirements

The Ambetter from Superior HealthPlanPreferred Drug List (PDL) is the list of covered drugs available through network pharmacies. The Ambetter from Superior HealthPlanPDL is continually evaluated by the Ambetter Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of Medical Directors, Pharmacy Directors, and providers, pharmacists, and other healthcare professionals.

Some medications may require prior authorization or other limitations consistent with Food and Drug Administration (FDA) recommendation for safe and effective use.

• Medical necessity decisions for non-expedited outpatient prescription benefit prior authorization requests are finalized, and notification of the determination to the member and prescribing provider completed within 3 calendar days.
• Medical necessity decisions for concurrent review of outpatient prescription drugs or intravenous infusions are finalized and notification of the determination provided to the member and prescribing provider not later than the 30th day before the date on which the provision of prescription drugs or intravenous infusions will be discontinued.
• Urgent/expedited requests for prior authorization of outpatient prescription benefits are finalized and notification of determination provided within the time appropriate to the circ*mstances relating to the delivery of the services to the member and to the member's condition, but typically within 24 hours of receipt of the urgent prior authorization request.

For a full listing of prior authorization requirements, please review:

• Ambetter’s Preferred Drug List (PDF),including quantity and age limits, prior authorization requirements, step therapy and formulary status; and
• Ambetter’s Clinical prior authorization requirements in the Biopharmacy and Pharmacy Policies, found onAmbetter's Clinical and Payment Policies webpage.

Timeframe For Determinations

Physical Health Services, Supplies and Equipment, Behavioral Health Services–Clinician Administered Drugs (CAD)

Pharmacy Benefits

Notification Of Admissions And Concurrent Review

• Prior authorization is required for all elective inpatient admissions.
• Prior authorization is NOT required for any urgent/emergent inpatient admissions that were not prior scheduled.
• Notification of non-elective inpatient admissions is required no later than the close of the next business day.
• Failure to notify within the timeframe required will result in a late notification denial, unless otherwise stated within a Superior contract.
• For notification of inpatient admission, please reference the phone and fax numbers below:

Inpatient Admissions

• Concurrent utilization review to determine the medical necessity for inpatient days for a hospitalized patient is completed within 24 hours of receipt of the notification of admission and receipt of clinical records.

Utilization Review Agents (URA)

Ambetter contracts with licensed Utilization Review Agents (URAs) who have the clinical expertise to conduct in the utilization review for applicable prior authorization. These include the following Texas licensed utilization review entities:

• Centene Company of Texas, LP (License #4167) – Physical Health, Behavioral Health and Clinician Administered Drugs
• Centene Management Company, LLC (License #5396) – Physical Health, Behavioral Health and Clinician Administered Drugs
• Centene Pharmacy Solutions, Inc. (License #1774935) – Prescription Services
• Texas National Imaging Associates, Inc. (License #5258) – Radiology Services, Cardiac Imaging, Physical, Occupational and Speech Therapy Services, Interventional Pain Management Services, Genetic Testing and Molecular Diagnostics,Molecular Diagnostics and Musculoskeletal Surgical Procedures
• Turningpoint Healthcare Solutions, LLC (License #2395464) –Cardiac Surgeries, ENT Services: Nasal/Sinus Endoscopy, Tonsillectomy & Adenoidectomy, Tympanostomy, Myringotomy