Authorization Request / Prior Authorization Submission Requirements
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This document governs the requirements for submitting prior authorization requests to CommunityCare Medical Management and describes what information must accompany requests to determine medical necessity. It applies to providers requesting authorization for services for CommunityCare members in North Carolina.
No material clinical or coverage changes in this revision.
Coverage and Authorization Criteria
Authorization validity
Covered when ALL of the following are met
Authorization does not guarantee payment; payment is subject to benefit plan limits and member eligibility
Authorization is an approval from CommunityCare Medical Management that the requested service has been determined medically necessary and appropriate; however, authorization does not guarantee payment. Payment remains subject to the member's benefit plan limits and the member's eligibility on the date the service is rendered. If the member is later determined to be ineligible or to have exceeded plan limits, the member is financially responsible and the service may be unpaid.
Coding Placeholders and Lists
| No codes listed |
Provider Responsibilities and Routing
Authorization does not guarantee payment or eligibility
Obtain prior authorization from CommunityCare Medical Management before providing the requested service; authorization reflects that CommunityCare determined the service medically necessary but does not guarantee payment or that the member will be eligible on the date of service.
Special Injectables/Medications routing
For requests involving Special Injectables or Medications, route the request to the Pharmacy Help Desk by faxing to 918-879-4309 or calling 918-594-5211 as directed on the form.
Required accompanying clinical information
Submit this completed authorization form along with all pertinent clinical information (for example, previous diagnostic testing, current medications, etc.) to Medical Management to allow determination of medical necessity.
Missing documentation may cause denial
Failure to include pertinent supporting clinical documentation with the request can result in denial of the authorization.
Background and Purpose
This Authorization Request form is intended to collect patient and service details and supporting clinical documentation so Medical Management can evaluate medical necessity for requested services. The form prompts for common service categories (for example, office visits, diagnostic testing, DME, and procedures) and for relevant diagnosis and CPT codes; it must be submitted with all pertinent clinical information to allow review.
Definitions and Service Category
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