Referral and Authorization Information

*Services above marked with an asterisk require prior authorization through Ambetter from Coordinated Care before receiving the service.

Prior Authorization for Services

Sometimes, we need to approve medical services before you receive them. This process is known as prior authorization. Prior authorization means that we have pre-approved a medical service.

To see if a service requires authorization, check with your Primary Care Provider (PCP), the ordering provider or Member Services. When we receive your prior authorization request, our nurses and doctors will review it. We will let you and your doctor know if the service is approved or denied.

Information about the review process, including the timeframes for making a decision and notifying you and your provider of the decision, is located in the Utilization Review section of your Member Handbook.

Failure to obtain prior authorization may result in a denied claim(s). To see a full listing of procedures and services that require PRIOR AUTHORIZATION, please log in to your secure member account to view your Schedule of Benefits.

The following services require the member’s provider to contact Ambetter from Coordinated Care for prior approval:

THE FOLLOWING LIST IS NOT ALL-INCLUSIVE

Ancillary Services

• Air ambulance transport
• Durable Medical Equipment (DME)
• Home health care services
• Hospice
• Furnished medical supplies
• Orthotics/prosthetics
• Genetic testing
• Quantitative urine drug screen

Procedures/Services

• Reconstructive Surgery
• Experimental or investigational
• High Tech Imaging administered by NIA (CT, MRI, PET)
  • Submit requests to RadMD.com

  Inpatient Admissions

  • All inpatient admissions (within 1 business day of admission)
  • Observation stays exceeding 48 hours
    • Notification is required within one (1) business day if admitted
    • Medical admissions
    • Surgical admissions
    • Hospice care
    • Rehabilitation facilities

    Out-of-Network Services: All out-of-network services and providers require prior authorization, excluding emergency services.

    You can also call your PCP or Ambetter from Coordinated Care Member Services with questions.

    All out-of-network services require prior authorization, excluding emergency room (ER) services.

    Ambetter from Coordinated Care is underwritten by Coordinated Care Corporation, which is a Qualified Health Plan issuer in the Washington Health Insurance Marketplace. This is a solicitation for insurance. © 2023 Coordinated Care Corporation. All rights reserved.