Prior Authorization
A Prior Authorization (PA) is an authorization from MHS to provide services designated as requiring approval prior to treatment and/or payment. All procedures requiring authorization must be obtained by contacting MHS prior to rendering services. PA is required for certain services/procedures which are frequently over- and/or underutilized or services/procedures which are complex and may indicate a need for case management.
Check to see if a pre-authorization is necessary by using our online tool located on the sidebar. It's quick and easy. If an authorization is needed, you can access our Provider Portal to submit online.
Expand the links below to find out more information.
For imaging, outpatient surgeries and testing, requests for services may be obtained via:
- Phone: 1-877-647-4848
- Fax: 1-866-912-4245
- Online: Provider Portal
For DME, orthotics, prosthetics, home healthcare, and therapy (physical, occupational, speech), requests for services may be obtained via fax only: 1-866-912-4245.
MHS will accept PA requests for emergent services up to two days following services for both contracted and non-contracted providers.
Previously-approved authorizations may be updated for changes in dates of service, servicing provider or CPT/HCPCS codes within 30 days of the original date of service. Authorization approval is for medical necessity only. If your claim subsequently denies, please contact MHS Provider Services at 1-877-647-4848 to determine the reason for the denial.
MHS strives to return a decision on all PA requests within two business days of the request but no later than seven calendar days. Reasons for a delayed decision include the following:
- Lack of information
- Illegible faxes
- Request requires Medical Director review
By logging on to the MHS Secure Provider Portal and completing an eligibility check, MHS will be notified of a ER visit by clicking on the Emergency Room Visit? tab.
You can find a full list of services requiring PA in our:
Prior Authorization Tools and Guides
- Use this tool to help identify if a service rendered will require prior authorization for Medicaid or Ambetter.
- Specialty Pharmacy PA Forms (PDF)
- Provider Quick Reference Guide (PDF)
Contracted providers
Contracted providers requesting authorization for elective/routine services must obtain a PA at least two days prior to the date of service to ensure an authorization determination occurs prior to rendering a service. MHS does allow requests for authorization from contracted providers up to two days after the date of service, subject to the appropriate medical review.
Non-contracted providers
Non-contracted providers must obtain authorization two days prior to the date of service. Retroactive authorizations will not be granted except in the event of an emergent situation. If a provider is unable to request a PA at least two business days in advance due to the emergent nature of the member’s condition, a PA request must be initiated within two business days following the date of service/admission. MHS will make every effort to expedite the request. All emergency admissions/services require authorization within two business days of the admission/service.
Failure to obtain PA as previously described will result in claims payment denials for late notifications. Claim denials may result when a claim is denied due to a failure to obtain PA for services where PA is required.