Precertification Requirements
Submission instructions
Simply Healthcare Plans, Inc. (Simply) and Clear Health Alliance (CHA) highly encourage the submission of precertification requests via the Availity Essentials platform.
All expedited service authorization requests must be submitted via the Availity Essentials platform. This will allow us to prioritize urgent service authorization requests appropriately, improve turnaround times, and reduce errors. Please do not send expedited service authorization requests via fax or phone call.
Standard precertification requests can be submitted via:
- Availity Essentials: https://essentials.availity.com/
- Phone: 844-405-4296
- Fax: 800-964-3627
UM Authorization Turnaround Times: (CHA)
- We process standard (non-expedited) authorization requests within the timeframes below:
- Requests submitted through Availity (Electronic Prior Authorization Portal) — Turnaround time: No more than three (3) days from receipt of the request.
- All other standard authorization submission methods (fax, phone) — Turnaround time: No more than four (4) days from receipt of the request.
- When is it appropriate to request an expedited authorization — turnaround time no more than two (2) days from receipt of request?
- An expedited request should be submitted only when a standard review timeframe could seriously jeopardize one or more of the following:
- The member’s life or health
- The member’s ability to regain or maintain maximum function
- The member’s safety due to rapidly worsening symptoms or urgent clinical circumstances
- The member’s clinical stability, where a delay could lead to avoidable hospitalization or a significant complication
- An expedited request should be submitted only when a standard review timeframe could seriously jeopardize one or more of the following:
* CHA may extend timeframes if the enrollee or the provider requests an extension or if CHA justifies the need for additional information and how the extension benefits the enrollee.
Behavioral Health
Carelon Behavioral Health Phone Numbers for Members and Providers:
- 1-844-375-7215: Medicaid
- 1-855-861-2142: Florida Healthy Kids
- 1-877-698-7787: Medicare
- 1-800-397-1630: Providers wanting to join Carelon Behavioral Health Network
Preauthorizations:
- 1-800-221-5487: IP, IOP, PHP, SIPP, RTC
- 1-844-375-7215: OP Medicaid
- 1-855-861-2142: FHK
Carelon Behavioral Health Fax Numbers:
- IP, IOP, PHP, SIPP, RTC Preauthorization: We do not accept faxes for this LOC, only phone calls.
- 1-800-370-1116: Medicare Outpatient Preauthorization
- 1-800-370-1116: Medicaid Outpatient Preauthorization
Join Network for Providers
- Contact the National Provider Services Line at 1-800-397-1630, Monday to Friday, 8 a.m. to 8 p.m. (EST) or visit Join Our Provider Network | Carelon Behavioral Health
Crisis Calls for Members
- 1-844-375-7215, Press 9, Press 1 for English or 2 for Spanish, Press 9 for Emergency, will then be transferred to a clinician
Pharmacy
Check our preferred drug list
Services billed with the following revenue codes ALWAYS require precertification:
0632 — Pharmacy multiple sources
Long-Term Services and Supports
Providers needing an authorization should call 1-877-440-3738.
The following ALWAYS require precertification:
Elective services provided by or arranged at nonparticipating facilities
All services billed with the following revenue codes:
0023 — Home health prospective payment system
0570–0572, 0579 — Home health aide
0944–0945 — Other therapeutic services
3101–3109 — Adult day and foster care
Precertification Tool
To request or check the status of a precertification request or decision, please login to Availity.