Prior Authorization Lookup Tool
Please verify benefit coverage prior to rendering services. Inpatient services and nonparticipating providers always require prior authorization.
- This tool is for outpatient services only.
- Inpatient services and nonparticipating providers always require prior authorization.
- This tool does not reflect benefits coverage* nor does it include an exhaustive listing of all noncovered services (in other words, experimental procedures, cosmetic surgery, etc.)— refer to your provider manual for coverage/limitations.
Enhanced Care Management (ECM) under CalAIM is a care management benefit that is community-based and provides a whole person approach to care that addresses the clinical and nonclinical needs of members with the most complex medical and social needs. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections.
Community Supports under CalAIM are voluntary wrap-around services or settings available to members as a substitute for utilization of other services that focus on medical and/or needs that arise from social determinants of health. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections.
* Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. Please verify benefit coverage prior to rendering services.
To determine coverage of a particular service or procedure for a specific member:
- Access eligibility and benefits information on the Availity Web Portal or
- Use the Prior Authorization Lookup Tool within Availity or
- Contact the Customer Care Center:
After hours, call the 24/7 NurseLine to verify member eligibility:
To request authorizations:
- From the Availity homepage, select Patient Registration from the top navigation.
- Select Auth/Referral Inquiry or Authorizations.
Provider tools & resources
- Log in to Availity
- Launch Provider Learning Hub Now
- Learn about Availity
- Prior Authorization Lookup Tool
- Prior Authorization Requirements
- Claims Overview
- Reimbursement Policies
- Provider Manuals, Policies & Guidelines
- Provider Training Academy
- Pharmacy Information
- Provider News & Announcements