Simplyhealthcare Prior Authorization Lookup
Latest Simplyhealthcare prior authorization updates9
- Prior AuthClinical/Medical PolicyEff. 2026-08-01Actimmune (interferon gamma-1b) prior authorizationPrior authorization criteria and coverage details for Actimmune and related specialty products for Simply Healthcare Plans members.All simplyhealthcare updates
- Prior AuthAdministrative/Operational PolicyEff. 2020-05-05COVID-19 State of Emergency: Behavioral Health Service RequirementsMandates managed care plans to waive prior authorization and service limits for all behavioral health services under the 2018-2023 SMMC contract benefits (MMA and MMA Specialty), effective during the COVID-19 state of emergency and until further notice; applies to Simply Healthcare Plans' SMMC lines indicated.All simplyhealthcare updates
- Prior AuthAdministrative/Operational PolicyEff. 2020-03-09Prior authorization and limits on servicesThis bulletin governs Simply Healthcare Plans' temporary changes to prior authorization and service limits for Florida Medicaid members during the COVID-19 state of emergency, affecting providers delivering inpatient, outpatient, home health, DME, pharmacy and related services.All simplyhealthcare updates
- Prior AuthAdministrative/Operational PolicyCOVID-19 State of Emergency: Medicaid Coverage of ServicesDirects managed care plans to modify prior authorization, service limits, cost sharing, appeals timing, enrollment/credentialing, and payment processes to ensure continuity of care for Medicaid enrollees during the COVID-19 state of emergency.All simplyhealthcare updates
- Prior AuthClinical Utilization Management Guidelines (CUMG) listThis document lists the Clinical Utilization Management Guidelines adopted by Simply Healthcare Plans and Clear Health Alliance for Medicaid managed care in Florida and explains their use in prior authorization and medical necessity determinations.All simplyhealthcare updates
- Prior AuthClinical/Medical PolicyClinical Utilization Management Guidelines (CUMG) listA master listing of Clinical Utilization Management Guidelines adopted by Simply Healthcare Plans, Inc., indicating titles and which items are new for use in medical necessity and utilization review processes for members (including Medicaid members). Affects network providers and internal reviewers who perform utilization management and prior authorization determinations.All simplyhealthcare updates
- Prior AuthClinical/Medical PolicyClinical Utilization Management Guidelines (CUMG) list for DME and other servicesThis document lists the Clinical Utilization Management Guidelines (CUMG) adopted by Simply Healthcare Plans, indicating guideline identifiers and titles across DME and other specialties; it governs medical necessity review and prior authorization processes used by Simply for applicable services.All simplyhealthcare updates
- Prior AuthClinical/Medical PolicyCoverage of Spinraza (nusinersen) and Exondys 51 (eteplirsen)Requirements and prior authorization routing for Spinraza (nusinersen) and Exondys 51 (eteplirsen) for Simply Healthcare Plans, Inc. and Clear Health Alliance members, including submission instructions and where additional criteria can be found. Affects providers requesting prior authorization for these medications.All simplyhealthcare updates
- Prior AuthReimbursement/Payment PolicyPreferred diabetic supplies (meters, strips, lancets, pen needles)Defines Simply Healthcare Plans and Clear Health Alliance preferred diabetic meters, test strips, lancets, and pen needles for Florida Medicaid and Florida Healthy Kids members and describes quantity limits, prior authorization requirements, and how to obtain preferred products.All simplyhealthcare updates
Tool Description
Search Simplyhealthcareprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
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Prior auth requirements change all the time. Keep up with every payer policy update in the live policy feed, or browse payers with prior authorization policies.
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