Prior Authorization
Ambetter Prior Authorization Information Requests **Will open into new window
Absolute Total Care’s Medical Management Department hours of operation are 8 a.m. to 6 p.m. (EST), Monday through Friday (excluding holidays).
Medical Management Telephone: 1-866-433-6041 (TTY: 711)
24/7 Nurse Advice Line
Our nurse advice line is a 24-hour nurse line for members. Our registered nurses provide basic health education and nurse triage, as well as answer questions about urgent or emergency access. To speak to a registered nurse, please call 1-866-807-4490 directly or call Member Services at 1-866-433-6041 (TTY: 711) and say “Nurse”.
A PCP referral is NOT required for a member to see an Absolute Total Care network specialist. However, Absolute Total Care recommends that members always check with their PCP before going to a see a specialist. PCPs should refer members to the appropriate specialist for care.
**EMERGENCY ROOM AND POST STABILIZATION SERVICES NEVER REQUIRE PRIOR AUTHORIZATION**
Medication Requests **Will open into new window
Some services require prior authorization from Absolute Total Care in order for reimbursement to be issued to the provider. See our Prior Authorization List, which will be posted soon, or use our Pre-Auth Check Tool.
Standard prior authorization requests should be submitted for medical necessity review at least 10 calendar days before the scheduled service delivery date or as soon as the need for service is identified.
Urgent requests will be reviewed within 72 hours from the time the request has been received.
Per the ATC Provider Manual Urgent is defined as “Services furnished to treat a medical condition that requires attention within 48 hours. If the condition is left untreated for 48 hours or more, it could develop into an emergency condition.
Non-urgent requests will be reviewed within 14 calendar days from the time the request has been received.
Urgent/emergent admissions require notification within one (1) business day following the admit date.
CONCURRENT REVIEW
We will process most routine authorizations within 72 hours. If we need additional clinical information or the case needs to be reviewed by the Medical Director, it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email or secure web portal.
POST ACUTE ADMISSION SUCH AS SNFS, SUBACUTE AND INPATIENT REHAB
**The Medical Management team will attempt to give priority to all requests for post-acute admissions for members who are currently in acute inpatient setting.**
Non-urgent requests will be reviewed within 14 calendar days from the time the request has been received.
Providers should contact Absolute Total Care’s Central Transplant Unit at 1-866-753-5659 for assistance with all potential or impending transplant cases. Transplant services covered by Absolute Total Care will not be reimbursed unless coordinated by an Absolute Total Care’s Care Manager.
All other transplant services remain a benefit of the Medicaid Fee-For-Service Program.
The Medicaid Peer-to-Peer Process (P2P) is available to any provider who is rendered a medical necessity denial. The intent of the P2P is to discuss the denial decision. To request a P2P regarding a denial, email SC_Appeals_and_Grievs@Centene.com, Fax: 866-918-4457, or call and 866-433-6041 ext. 63907.
**Authorizations that are administratively denied or because no clinical information was submitted with the request are NOT eligible for a P2P**
The following information is needed to be considered a valid peer to peer request:
- Provider name
- Provider phone number
- Member name
- Member DOB
- Authorization #
- The caller’s contact information
- Provider’s available date and time(s). Availability must be within 7 calendar days from the date we receive a valid P2P request.
Please note: ATC will make every attempt to accommodate these times, however, this may not be possible for narrow windows. Therefore, we recommend a minimum of a 2 hour window on at least 2 different days.
The provider/facility must request the peer-to-peer within 5 business days of the initial notification of the denial.
Absolute Total Health has 2 business days to acknowledge Peer-to-Peer requests.
If the Absolute Total Health Medical Director returns the Peer-to-Peer request and leaves a message, the provider has 1 business day to return the call, or the denial will be upheld, and the provider will need to file an appeal (with the written consent from the member).
**This is the process for Absolute Total Care Medicaid authorizations only. Please refer to the denial notification or UM Contact information for Ambetter, Wellcare, Allwell by Absolute Total Care, Wellcare Prime by Absolute Total Care, Envolve Pharmacy, Turning Point, or NIA authorizations**
Inpatient and Outpatient Prior Authorization Forms **Will open into new window
| Fax Number Reference Guide | Phone Number |
|---|---|
| Absolute Total Care Medicaid Face Sheets | 866-653-6349 |
| Absolute Total Care Medicaid Assessments | 866-653-6961 |
| Absolute Total Care Medicaid Inpatient Requests | 866-653-6349 |
| Absolute Total Care Medicaid Medical Records | 866-653-6349 |
| Absolute Total Care Medicaid Prior Authorization | 866-912-3606 |
| Absolute Total Care Medicaid Census Report | 866-653-6349 |
| Absolute Total Care Pharmacy Buy & Bill Prior Authorizations | 866-865-9469 |
| Absolute Total Care Inpatient Behavorial Health PA |
866-535-6974 |
| Absolute Total Care Outpatient Behavioral Health PA | 866-694-3649 |
| Absolute Total Care Care Transplants | 866-535-6974 |