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 MI Coordinated Health 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 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 (Preferred) | For issues or questions with portal login, please contact provider services at 1-833-230-2159. For additional information or questions about HAP CareSource MI Coordinated Health benefits, please visit the Provider Manual or contact Provider Services. |
Phone | |
Fax | 844-633-0399 |
Sick Newborn Fax | 937-396-3499 |
HAP CareSource MI Coordinated Health |
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 All in-patient services require prior authorization. Outpatient emergency services do not require prior authorization. | |
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 for imaging procedures at RadMD’s website.