Prior Authorization-es

CareSource^® evaluates prior authorization requests based on medical necessity, medical appropriateness, and benefit limits.

Transition of Care

CareSource will coordinate continuity of care for members who have existing care treatment plans that include scheduled services with non-participating health partners or who transition to or from another payer including those members identified as having special health care needs. For continuity of care request approvals for non-participating primary care providers, 30 days of service will be allowed for the non-participating health partner to transfer care to the network primary care provider.

The provider will have to provide evidence of the authorization of the services from GAMMIS or the method you received verification of services. CareSource will provide an authorization from the date of eligibility with CareSource to the end of the already approved service. The provider will have to submit a request for any additional services for review of medical necessity outside these dates of service prior to transition.

CareSource will need to be contacted via phone at 1-855-202-1058 or fax at 1-844-676-0370 as there needs to be an authorization in our system that matches the billed services.

Services That Require Prior Authorization

Please refer to the Procedure Code Lookup Tool to check whether a service requires prior authorization. All services that require prior authorization from CareSource should be authorized before the service is delivered. CareSource is not able to pay claims for services in which prior authorization is required but not obtained by the provider.

• Navigate 2022 Prior Authorization List

Prior Authorization Procedures

The preferred method for submission of prior authorization requests is through the use of Georgia’s Department of Community Health (DCH) centralized prior authorization portal. This feature allows submission of prior authorization requests through a centralized source, the Georgia Medicaid Management Information System (GAMMIS). For questions related to prior authorization for health care services, you can contact the CareSource Medical Management department by phone, fax, or mail.

Phone: 1-855-202-1058

Fax: 1-844-676-0370

Mail:

CareSource
Attn: Medical Management Dept.
P.O. Box 1598
Dayton, OH 45401-1598

Written request should only be submitted if the provider is not able to submit via the GAMMIS Centralized Prior-Authorization Portal due to technical issues. If written prior authorization requests need to be submitted, they should be submitted on the Navigate Medical Prior Authorization Request Form.

Nonparticipating Providers

Prior authorization must be obtained before sending patients to nonparticipating providers, with the following exceptions:

Emergency Services

 All in-patient services require prior authorization. Please submit request by Georgia Medicaid Management Information System (GAMMIS) to obtain prior authorization for emergency admissions. Outpatient emergency services do not require prior authorization.

Post Stabilization Services

Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting by a participating provider.

To request prior authorization for observation services as a nonparticipating provider or to request authorization for an inpatient admission, please submit by Georgia Medicaid Management Information System (GAMMIS).

Please call 1-855-202-1058 for any questions related to post-stabilization services.

Pharmacy Prior Authorization

Some drugs may require prior authorization before they will be covered. Please refer to the Pharmacy page to review these requirements.

For drugs processed through Express Scripts, please refer to the Formulary or Preferred Drug List (PDL) on the Drug Formulary page. For drugs through the medical benefit, please refer to the Procedure Lookup Tool and Authorization Requirements for Medications Under the Medical under Prior Authorization.

• Pharmacy Prior Authorization Request Form – Submit this form to request prior authorization to prescribe pharmacy medications under the pharmacy benefit.
• Specialty Pharmacy Prior Authorization Request Form or Universal 17P Authorization Form – Submit one of these forms to request prior authorization to prescribe specialty pharmacy medications, as outlined in the CareSource member’s plan Preferred Drug List (PDL).
• Synagis Prior Authorization Request Form – Submit this form to request prior authorization to prescribe Synagis.
• Medication Assisted Treatment Prior Authorization Form – Submit this form to request prior authorization for buprenorphine products.
• Immediate Release Opioid Prior Authorization Form – Submit this form to request prior authorization for immediate release opioids.
• Extended Release Opioid Prior Authorization Form – Submit this form to request prior authorization  for extended release opioids.

Dental Prior Authorization

Our dental provider manual and other dental resources are available on the Skygen Dental Provider Web Portal.

Advanced Imaging Prior Authorization

Ordering physicians must obtain prior authorization for the following outpatient, non-emergent diagnostic imaging procedures:

• MRI/MRAs
• CT/CTA scans
• PET scans

Ordering providers can obtain prior authorization from NIA for imaging procedures at RadMD’s website.