Carolina Complete Health Standard Plan Pre-Auth Tool
Tailored Plan Pre-Auth Tools
For Trillium physical health pre-auths, please see the Trillium Pre-Auth Check tool.
For Partners physical health pre-auths, please see the Partners Pre-Auth Check tool.
Pharmacy Prior Authorization
For Pharmacy or Medication related authorizations including:
- Home Infusion Therapy
- Physician Administer Drug Program
- Outpatient Pharmacy Medication
There is no prior authorization required for sexually transmitted infection and/or tuberculosis services rendered at Local Health Department. Please use the PA Tool below to determine if a PA is needed for other services.
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 provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
Vision Services need to be verified by Centene Vision. Nash Optical Plant continues to fabricate Medicaid eyeglasses, therefore continue obtaining PA through NCTracksfor eyeglasses.
Dental Services are administered by the State.
Complex imaging, MRA, MRI, PET, and CT scans need to be verified by Evolent.
Interventional Pain Management needs to be verified by Evolent
Non-participating providers must submit Prior Authorization for all services.
For non-participating providers, Join Our Network.
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
- Service requests that are over the benefit limit or a non-covered code
Prior Authorization Check
To submit a prior authorization to Carolina Complete Health Login Here
To submit a prior authorization to Evolent for Complex Imaging, Interventional Pain Management, or Musculoskeletal Services, Login Here