Prior Authorization and Notification Process
Many service do not require pre-authorization, but before providing care we request that you confirm the prescribed service is covered under Member’s benefit plan by contacting our Provider Service Center or by logging in with your provider credentials here and checking coverage in our new prior-authorization web page.
- Authorizations processed by AvMed must be requested on an Authorization Request and submitted via the web or via fax.
- Urgent and Emergent requests may be submitted via our new prior-authorization page on the provider portal, but may also be handled telephonically or via fax.
- Authorization request forms for routine/urgent pre-service and Emergency room admissions can be found under forms.
- Telephone and fax numbers are conveniently located on all authorization request forms, but we have included below a list of important phone and fax numbers.
The services listed below require an authorization from AvMed or a contracted Vendor:
- Inpatient Hospitalization - Acute, Observation, Elective, Newborn, Skilled nursing and Rehabilitation.
- Mental Health Services (Inpatient admissions and Outpatient treatment) must be approved through our capitated Provider.
- Outpatient and in-office complex radiological procedures – CAT Scan, MRI, MRA, Pet scan, CT Angiography, Nuclear / Cardiac imaging and Nuclear Medicine are handled by NIA for most products (access NIA via the Provider portal).
- Individual Plans are processed by AvMed and requests for these services should be submitted to AvMed.
- Outpatient surgery in an ambulatory surgery center or hospital setting except for certain CPT 4 codes.* (These surgical CPT 4 codes that can be found here using your provider number and PIN.)
- Outpatient drug infusions and injections performed in an outpatient facility or infusion suite.
- In-Office Drug Administration requests may be submitted through our on-line Prior Authorization system NovoLogix. Providers must enter through the Provider portal using your provider number and Pin.
- Wound Care Center and Hyperbaric Oxygen Therapy (HBO) services
- Hemodialysis services
- Transplant services
- Non-participating Provider services
- Pain management services including surgical procedures when provided in an outpatient facility (ambulatory surgery center/hospital setting).
- Ophthalmology services (see list of surgical ophthalmology codes that requires prior authorization)
- Important phone and fax numbers.
- Routine fax request 1-800-552-8633
- Urgent fax request 1-888-430-9897
- Nurse Reviewers Phone 1-800-816-5465
- Provider Service Center phone 1-800-452-8633
For complete details on authorization requirements, please see chapter 3 of AvMed's Physician's Reference guide.