General authorization submission requirements — verify eligibility and obtain prior authorization when required

Providers must verify member eligibility and benefits on the date of service and obtain prior authorization for non-emergent services when required. Authorizations processed by AvMed must be requested electronically via the AvMed Authorization and Referral Tool (AART) in the Provider Portal (preferred) or by completing a Medical Prior Authorization Request form and faxing to 1-800-552-8633. Submit requests in accordance with CMS/NCQA guidelines to allow determinations within standard turnaround times. Non-urgent/standard pre-service requests are decided within 15 calendar days for commercial plans and 14 calendar days for Medicare plans. Urgent/expedited pre-service requests are decided within 72 hours; urgent concurrent requests within 24 hours. An authorization is not a guarantee of payment; payment is subject to member eligibility, benefits, and provider contract on the date of service.

• Preferred submission: AART via Provider Portal
• Fax option: Medical Prior Auth Request Form to 1-800-552-8633
• Follow CMS/NCQA guidelines for submission timing
• Authorizations are required for services listed unless an exception applies

Inpatient and facility authorization rules — which admissions and facility stays require authorization

All inpatient admissions and observation stays for surgical and non-surgical care require authorization notification prior to or at admission (Hospital Use only - Emergent, Urgent, Direct Admissions exceptions apply). Maternity and newborn confinements require authorization. Inpatient stays in Skilled Nursing Facility (SNF), Long Term Acute Care (LTAC), and Acute Rehabilitation facilities require prior authorization. Emergency room visits without an overnight stay do not require authorization. Behavioral Health and Substance Abuse inpatient and outpatient hospital services require authorization via Optum Behavioral Health.

• All inpatient admissions and observation stays require authorization/notification
• Maternity and newborn confinements require authorization
• SNF, LTAC and acute rehab admissions require prior authorization
• ER visits without overnight stay do not require authorization
• Behavioral Health inpatient/outpatient hospital services authorized by Optum

Chemotherapy authorization routing — New Century Health routing for outpatient chemotherapy and related notes

Outpatient chemotherapy and hematology treatment requests and supportive medications for Medicare Advantage plans require review/authorization by New Century Health (NCH). Providers should use the NCH provider web portal (https://my.newcenturyhealth.com) or call 1-888-999-7713 (Mon–Sat, 8 a.m.–8 p.m. ET). For outpatient chemotherapy for Fully Insured or Self-Insured Commercial products, AvMed manages authorizations directly. Inpatient chemotherapy authorization requests for all members must be submitted to AvMed. Specialty medication prior authorizations for Commercial and Self-Insured plans are handled by NovoLogix via their web-based preauthorization tool (access via the AvMed Provider Portal). For other chemotherapy requests, complete the Medical Prior Authorization Request form and fax to 1-800-552-8633.

• Medicare Advantage outpatient chemo: New Century Health review (https://my.newcenturyhealth.com; 1-888-999-7713)
• Commercial outpatient chemo: managed by AvMed
• Inpatient chemo: contact AvMed for authorization
• Specialty meds (Commercial/Self-Insured): NovoLogix via AvMed Provider Portal
• Alternate submission: Medical Prior Auth Form fax 1-800-552-8633

Dermatology authorization notes — DNS routing for Medicare members and AvMed-managed plans, plus surgical dermatology notes

Dermatology for Medicare members is authorized by Dermatology Network Solutions (DNS). DNS can be reached at 305-667-8787 or fax 305-402-2269. Dermatology services for other benefit plans are managed by AvMed. A referral is not required for in-network dermatologists; however, prior authorization may be required for certain surgical dermatology procedures.

• Medicare Plan members: DNS handles dermatology authorizations (Phone: 305-667-8787; Fax: 305-402-2269)
• All other plans: AvMed manages dermatology authorizations
• In-network dermatologists do not require a referral
• Certain surgical dermatology procedures may require prior authorization

Ophthalmology authorization pathways — HN1/EMI network processes and AART/fax submission options

Ophthalmology authorization pathways differ by provider network. For Medicare Advantage members whose services are part of Health Network One (HN1)/Eye Management Inc. (EMI), the HN1/EMI provider obtains authorization/control numbers via HN1 (www.myemifl.com; call 1-800-329-1152 option 1; fax 305-868-7640 or 800-922-4132). Non-HN1 providers (Medicare Advantage and Commercial members) should submit authorization requests through AvMed via AART (preferred) or by faxing the Medical Prior Authorization Request form to 1-800-552-8633. Some non-HN1 providers will require authorization for both procedure and facility through AvMed for Medicare Advantage members.

• HN1/EMI providers: use HN1 (www.myemifl.com; 1-800-329-1152 option 1; fax 305-868-7640 or 800-922-4132)
• Non-HN1 providers: submit via AART (preferred) or fax to 1-800-552-8633
• Check the AvMed Ophthalmology CPT/code list for procedure-specific guidance
• AvMed in-network facility auth requirements: none

Podiatry authorization vendor — PNS contact for all members and surgical procedure prior auth notes

Podiatry authorizations are coordinated through Podiatry Network Services (PNS) for all members. Contact PNS at 844-222-3939. Surgical podiatry procedures may require prior authorization. Always verify whether a specific procedure is on AvMed's No Authorization Required list before assuming no auth is needed.

• Contact PNS for all members: 844-222-3939
• Surgical podiatry procedures may require prior authorization
• Refer to AvMed No Authorization Required list to confirm exceptions