Step-by-step guide for prior authorization
Many procedures require prior authorization (PA) before you can treat your patients. Our goal is to make this process as easy as possible. This section provides information on:
- How to submit an authorization request, and
- The documentation required when submitting.
Note: The agency contracts with Comagine Health to provide web-based access for reviewing medical necessity for the following Apple Health (Medicaid) services:
Outpatient advanced imaging services
Select surgical procedures
Outpatient advanced imaging
Spinal injections, including diagnostic selective nerve root blocks
To learn more about Comagine Health, view "Medical Necessity Review by Comagine Health" in the Physician-related/health care professional services billing guide.
On this page
Note: If the client is in a managed care plan, please contact the plan for coverage and prior authorization requirements. To access other health plans, visit OneHealthPort.
Use our provider billing guides and fee schedules to review policy and find out whether a code or service requires prior authorization.
- National Correct Coding Initiative (NCCI)
HCA's authorization services do not consider National Correct Coding Initiative (NCCI) guidelines when processing a request. Make sure your office checks the NCCI guidelines prior to submission.
Important: Inadvertently approved authorizations do not guarantee claims payment.
For questions about NCCI please refer to The National Correct Coding Initiative in Medicaid.
- Find the program or service that corresponds to the service(s) or item. (Programs and services are listed in alphabetical order.)
- Click the program or service name to expand the listing. Here you will find billing guides and fee schedules for that program or service.
- Open the appropriate billing guide and/or fee schedule based on the date of service to search for the code or service.
Important: Check the code or service in the fee schedule and provider guide for where the services will be performed. You may have to check multiple schedules or guides based on place of service. For example: Check the physician fee schedule and the ambulatory surgery center (ASC) fee schedule if you are performing the service in an ASC to:
- Make sure that it is covered for the location where you are performing the service, and
- See whether a PA is required for that place of service.
Billing guide/fee schedule quick links
The following is a shortened list of regularly used billing guides and fee schedules.
- Complex Rehabilitation Technology (CRT)
Note: All codes on this fee schedule require prior authorization
- Dental Program
- Medical equipment (ME)
- Orthodontic services
- Physician-related/professional services
- Prescription Drug Program
For a complete list, visit our Provider billing guides and fee schedules webpage.
All services or items requiring prior authorization must be submitted on the General Information for Authorization (form 13-835), each individual service or item may require additional forms. View a list of all prior authorization forms on our Forms and publications webpage.
Commonly used forms
One of the following forms is required to initiate the prior authorization process.
Submit by mail not available at this time: The agency is no longer accepting prior authorizations requests or supporting documentation by mail. Please submit by direct data entry or by fax.
By direct data entry (DDE) in the ProviderOne portal
Providers can direct data enter authorization requests directly into the ProviderOne System. This feature includes the ability to attach records, color photos, and x-rays. Upon successful submission, a provider will receive a 9-digit reference number; the reference number is verification that the agency has received your request. Providers must not bill or perform a procedure(s) until the agency has provided written approval. This new function does not change the way the agency processes prior authorization requests, the agency will still process requests in the order received. Please ensure that when submitting a prior authorization request that the required documentation is included along with a fax number. See the self-service training resources below:
- DDE authorization for dental providers
- DDE authorization for medical providers
- DDE authorization for ME providers
Complete the General Information for Authorization form (13-835) with all supporting documentation and fax it to: 1-866-668-1214.
Note: The General Information for Authorization form (13-835) must be typed and be page 1 of your fax to avoid delays. Do not include a fax coversheet.
- Submit x-rays or photos (if required)
Use FastAttachTM services provided by Vyne Dental (formerly NEA).
- If you are not already registered, register at reg.nea-fast.com. For more information contact: 1-800-782-5150, ext. 1.
- Fax your request to the agency and indicate the FastAttach# in the NEA #18 field on the PA request form.
There is a cost associated which will be explained by Vyne Dental.
Submit supporting documentation to an existing authorization
Use one of the following cover sheets when submitting supporting documents to an already existing authorization: For example, when responding to a pend for additional information, or an existing approved authorization requires a billing code or NPI update.
For step-by-step instructions: view our guide for adding supporting documents to an existing request in pend or approve/hold status.
Learn how to check authorization information in ProviderOne.
- Check the status of an authorization
- Retrieve correspondence for an authorization
- Appendix G
- Checking status through our interactive voice response (IVR) system starts on slide 24.
Submitting prior authorization for medical and dental services (webinar presentation slide deck)
- Submitting authorization requests for pharmacy services (webinar presentation slide deck)
Checking status through our IVR starts on slide 22.
The EPA process is designed to eliminate the need for written requests for prior authorization for selected services/items.
To view a list of qualifying services, download our EPA inventory.
Following certain criteria, the agency allows for use of an EPA. Criteria are explained in each of the program provider guides.
- The EPA number must be used when the provider bills the agency.
- Upon request, a provider must provide documentation to the agency showing how the client's condition meets all the criteria for EPA.
- A written request for prior authorization is required when a situation does not meet all the EPA criteria.
- The agency may recoup any payment made to a provider if the provider did not follow the required EPA process and if not all of the specified criteria were met.
Note: By entering an EPA number on your claim, you attest that all the EPA criteria are met and can be verified by documentation in the client's record. These services are subject to postpayment review and audit by the agency or its designee.