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.
HAP CareSource does not require referrals to see an in-network specialist. The specialist may require a referral from the member’s PCP. Some services and procedures require prior authorization. Referrals and prior authorizations must be obtained prior to services being rendered.
Prior Authorization Statistics
- Please access the Interoperability Prior Authorization Report to view the latest statistics.
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 | 1-833-230-2102 |
Fax | 1-844-432-8931 |
Sick Newborn Fax | 1-937-396-3499 |
HAP CareSource |
Please note: Written prior authorization requests should be submitted on the Medical Prior Authorization Request Form.
Urgent requests should be marked urgent. Urgent requests will be accepted when the member or their physician believes waiting for a decision under the standard time frame could place the member’s life, health or ability to regain maximum function in serious jeopardy. Referrals and prior authorization for services should be made to in-network providers whenever possible. Contracted providers can be found in our online Provider Directory.
Non-Participating 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. 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. All in-patient services require prior authorization. Outpatient emergency services do not require prior authorization. | Phone: 1-833-230-2102 Fax: 1-844-432-8931 |
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. |
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, formerly known as NIA, 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.
Dental Prior Authorization
Our dental provider manual and other dental resources are available on the Delta Dental Provider Web Portal.
Obtaining a Remittance Advice (RA)
To access your RA, log in with your username and password.
Continuity of Care
HAP CareSource will coordinate continuity of care for members who have existing care treatment plans that include scheduled services with nonparticipating health partners or who transition to or from another payer including those members identified as having special health care needs. For continuity of care request approvals for nonparticipating primary care providers, 30 days of service will be allowed for the nonparticipating health partner to transfer care to the network primary care provider.
The provider will have to provide evidence of the authorization of the services from the received verification of services. HAP CareSource will provide an authorization from the date of eligibility with HAP CareSource to the end of the already approved service. The provider will have to submit a request for any additional services for review of medical necessity outside these dates of service prior to transition.
HAP CareSource will need to be contacted via phone at 1-833-230-2102, as there needs to be an authorization in our system that matches the billed services.