Prior Authorization
We evaluate prior authorization requests based on medical necessity, medical appropriateness, and benefit limits.
Services That Require Prior Authorization
Please refer to the Procedure Code Lookup Tool to check whether a service requires prior authorization. All services that require prior authorization from us should be authorized before the service is delivered. We are not able to pay claims for services in which prior authorization is required but not obtained by the provider.
Prior Authorization Submission Options
The Provider Portal is the preferred and faster method to request prior authorization for health care services. You can receive immediate approval and also review the status of an authorization
| Method | Contact Info |
|---|---|
Provider Portal | If you need assistance with submitting your prior authorization or have questions regarding submissions via the Provider Portal, please email CiteAutoAssistance@caresource.com and a representative will be in contact. This email is only for assistance and questions regarding prior authorizations within the Provider Portal. |
Phone | |
Fax | 1-844-542-2608 |
Sick Newborn Fax | 937-396-3499 |
CareSource PASSE |
The following is a list of available Prior Authorizations Forms:
- ABA Prior Authorization Form
- CES Waiver Prior Authorization Form
- Community Based/Behavioral Health Outpatient Prior Authorization Form
- EIDT/ADDT and ST/PT/OT Prior Authorization Form
- Environmental Modification Monitoring and Waiver of Release
- ICF / Respite / HDC Prior Authorization Form
- Medical Prior Authorization Form
- Personal Care Prior Authorization Form
- Psych Inpatient / ICF Prior Authorization Form
- Supportive Living Prior Authorization Request Form
- Therapeutic Communities Prior Authorization Request Form
Nonparticipating Providers
Prior authorization must be obtained before sending patients to nonparticipating providers, with the following exceptions:
| Service Type | Contact Information |
|---|---|
| Emergency Use of emergency services does not require authorization. Admissions that result from emergency room visits do require authorization. AR PASSE only: Providers must obtain an Arkansas Medicaid ID to bill for Emergency Services. Please visit the Arkansas Department of Human Services webpage to apply for an Arkansas Medicaid ID. | 1-833-230-2100 |
| Post Stabilization Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting by a participating provider. | 1-833-230-2100 |
Advanced Imaging Prior Authorization
Ordering physicians must obtain prior authorization for the following outpatient, non-emergent diagnostic imaging procedures:
- MRI/MRAs
- CT/CTA scans
- PET scans
Ordering providers can obtain prior authorization from Evolent for imaging procedures at RadMD’s website.
Pharmacy Prior Authorization
Some drugs may require prior authorization before they will be covered. Please refer to the Pharmacy page to review these requirements.
Behavioral Health Prior Authorizations
- 2022 Behavioral Health Medicaid Benefits Continuum Resource
- 2022 HCBS Medicaid Benefits Continuum Resource