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Medicaid Pre-Auth

DISCLAIMER: 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 on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the Medicaid Provider Manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.

 

Prior authorization for medications will NOT be accepted through the web portal.

For Pharmacy prior authorization requests, please visit our pharmacy page.

  • Vision Services need to be verified by Envolve Vision.
  • Hospice requests should be submitted to SC DHHS Medicaid Fee for Service program.
  • Oncology/supportive drugs need to be verified by Evolent.
  • Dental services for members under 21 need to be verified by SCDHHS through the EPSDT program.
  • Complex imaging, MRA, MRI, PET, CT scans, Interventional Pain Management and Musculoskeletal Services need to be verified by Evolent.
  • Outpatient rehabilitative and habilitative physical medicine services PT, OT, and Speech need to be verified by Evolent.*Note - excludes services in the home setting.

For non-participating providers, Join Our Network.

Prior authorization is required for all non-emergent services provided by non-contracted providers. 

 

Prior Authorization at a Glance

Prior Authorization is NOT Required

The following services do NOT require prior authorization:

  • Services rendered in an emergency room or urgent care center
  • Services rendered by a public health or welfare agency
  • Family planning services billed with a contraceptive management diagnosis

Prior Authorization IS Required

The following services REQUIRE prior authorization:

  • Services rendered by an out out-of-network provider, with the exception of emergency and urgent care services
  • Admission of a member to an inpatient facility
  • Hospice services
  • Anesthesia services for pain management or dental procedures.
  • Services rendered at home, other than DME, orthotics, prosthetics, supplies and therapeutic injections
  • Services rendered by a chiropractor

Prior Authorization Check

To submit a prior authorization Login Here

If an authorization is needed, you can log in to your account to submit one online or fill out the appropriate fax form on the Provider Manuals and Forms page.