Services - Prior Authorization
Use the MPC Pre-Authorization tool to see if a prior authorization is needed. It’s quick and easy!
If an authorization is needed, you can submit online.
- MPC Medical Benefit Drug (Buy & Bill)
- Behavioral Health Services need to be verified by Optum Maryland
- Vision Services need to be verified by Superior Vision
- Dental Services need to be verified by DentaQuest
- Complex Imaging, MRA, MRI, PET, and CT Scans need to be verified by NIA
- Rehabilitative and habilitative therapy services, including those rendered by Chiropractors (Beginning 03.01.2021) need to be verified by NIA
- Non-emergent musculoskeletal procedures including outpatient, interventional spine pain management services need to be verified by NIA
- Oncology Treatment Plans, including Simulation & Planning, to be verified by Eviti
Disclaimer: Non-participating providers must obtain prior authorization for all services except for emergent and self-referred services.
Services Requiring Prior AuthorizationWe are updating the search tool to include all codes. In the interim, please note the following situations that require prior authorization in addition to what is available in the tool. If the code is not found, contact Clinical Review at (800) 953–8854, options 2 then 4.
- All non-emergency elective hospital admissions require prior authorization.
- All oncology and radiation oncology services require prior authorization and must have an Eviti Code prior to submitting the Prior Authorization request. Please contact Provider Services regarding access to our current oncology and radiation oncology services vendor at www.eviti.com.
- After the initial evaluation, rehabilitative and habilitative therapy services, including those rendered by Chiropractors, require prior authorization. Services rendered in a hospital emergency department, observation unit, or inpatient unit; in an acute rehabilitation hospital; or in a skilled nursing facility do not require authorization. Please contact National Imaging Associates (NIA) prior to or within 5 business days of rendering services. NIA can be reached at www.RadMD.com or via NIA’s call center at (800) 424-4836.
- Certain non-emergent outpatient cardiac procedures require prior authorization. These services include CT/CTA, MRI/MRA, PET Scan, CCTA, Myocardial Perfusion Imaging, MUGA Scan, Stress Echocardiography, and Echocardiography (TTE/TEE). Cardiologists may receive authorizations by contacting NIA at www.RadMD.com or via NIA’s call center at (800) 424- 4836. Approved authorizations will have a validity period of 60 days from the date of request.
- Prior authorization is required for high tech radiology and non-emergent musculoskeletal procedures including outpatient, interventional spine pain management services. These authorizations are obtained through NIA at www.RadMD.com or via NIA’s call center at (800) 424-4836.
- Maryland Physicians Care requires laboratory and radiology services to be done in free-standing (non-regulated) facilities. Authorization will be required for services performed in hospital/facility (regulated) space. Certain radiology and laboratory services may require prior authorization regardless of place of service.
- Maryland Physicians Care requires all defined CMS outpatient procedure to be rendered in an Ambulatory Surgical Center (ASC). Authorization will be required for services performed in hospital/facility (regulated) space. Certain procedures require prior authorization regardless of place of service.
- Outpatient hospital or facility-based surgical services may require prior authorization.
- Durable medical equipment, homecare, therapy, and hospice require prior authorization. To see which procedures require prior authorization, access the Pre-Auth Check tool below.
- Non-participating providers must obtain prior authorization before rendering any service other than emergency services. Participating providers must obtain prior authorization before rendering any service that is not exempt from prior authorization requirements. Services that require prior authorization may be denied if prior authorization has not been obtained.
MPC Medicaid Pre-Authorization Tool
Enter the code of the service you would like to check:
Non-participating providers require prior authorization for all services except for emergent and self-referred services. For non-participating providers, learn how you can become an MPC provider.
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. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
For specific details about authorization requirements, please refer to our Quick Reference Guide.