Medicaid 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, 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.
Vision services need to be verified by Envolve Vision Services
Dental services, (D0000-D9999), need to be verified by Envolve Dental
Musculoskeletal, Complex Imaging, MRA, MRI, PET, CT Scans, High Tech Radiology and Cardiac need to be verified by Evolent
ENT and Cardiac Services need to be verified by TurningPoint
Behavioral Health/Substance Abuse need to be verified by Peach State Health Plan.
Non-participating providers must submit prior authorization for all services.
For non-participating providers, Join Our Network
Are services being performed in the Emergency Department or Urgent Care Center or Family Planning services billed with a contraceptive management diagnosis?
| Types of Services | YES | NO |
|---|---|---|
| Is the member being admitted to an inpatient facility? | ||
| Are services being rendered in the home, excluding DME, Medical Equipment Supplies, Orthotics, Prosthetics and Sleep Studies and Home Health Administered Medications and Home Infusion? | ||
| Are anesthesia services being rendered for pain management? |
To submit a prior authorization Login Here.
CMS Interoperability & Prior Authorization Final Rule: CY2025 Prior Authorization Requirements Reports and Metrics Summaries
In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS 0057 F), we are annually publishing our prior authorization requirements and performance metrics to promote transparency, accountability, and better support our members and providers.
Reports:
- Peach State Health CMS Final Rule 0057-F Prior Authorization Requirements: 4 (PDF)
- Peach State Health Prior Authorization Metrics Summary: 4 (PDF)
The data presented in these publications reflects prior authorization requests processed during the applicable measurement year in accordance with CMS reporting specifications. Metrics are calculated using CMS defined methodologies and may not be directly comparable to alternative reports or third party summaries.