Medicare Pre-Auth
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 Medicare Advantage provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
To Submit a prior authorization Login Here
The following services need to be verified by Evolent:
- Complex imaging, MRA, MRI, PET, and CT scan
- Musculoskeletal services
- Pain management services
- Cardiac Services
Non-participating providers must submit Prior Authorization for all services.
For non-participating providers, Join Our Network
Are services being performed in the Emergency Department or Urgent Care Center, or are the services for dialysis or hospice?
| Types of Services | YES | NO |
|---|---|---|
| IS THE MEMBER BEING ADMITTED TO AN INPATIENT FACILITY? | ||
| ARE ANESTHESIA SERVICES BEING RENDERED FOR PAIN MANAGEMENT, DENTAL SURGERY, OR SERVICES IN THE OFFICE RENDERED BY A NON-PARTICIPATING PROVIDER? | ||
| IS THE MEMBER RECEIVING GENDER REASSIGNMENT SERVICES? | ||
| IS THIS AN HMO OUT OF NETWORK SERVICE REQUEST? |
To submit a prior authorization Login Here.
CMS Interoperability & Prior Authorization Final Rule: CY2025 Prior Authorization Requirements Reports and Metrics Summaries
In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS 0057 F), we are annually publishing our prior authorization requirements and performance metrics to promote transparency, accountability, and better support our members and providers.
Reports:
- Wellcare By Allwell CMS Final Rule 0057-F Prior Authorization Requirements: H1664 (PDF)
- Wellcare By Allwell Prior Authorization Metrics Summary: H1664 (PDF)
The data presented in these publications reflects prior authorization requests processed during the applicable measurement year in accordance with CMS reporting specifications. Metrics are calculated using CMS defined methodologies and may not be directly comparable to alternative reports or third party summaries.