Prior Authorizations

• Behavioral health urgent care (BHUC)
• Facility-based crisis services for children and adolescents (within two business days post service)
• Mobile crisis management (first 32 units and within two business days post service)
• Professional services in facility-based crisis programs (within seven business days/112 units)

• All out-of-network services except emergency services
• Ambulatory detoxification
• Behavioral health partial hospitalization
• Electroconvulsive therapy (ECT)
• Medically supervised alcohol or drug abuse treatment center detoxification crisis stabilization/ADATC (following first eight hours or one business day of admission)
• Mobile crisis management (for units beyond the initial 32)
• Non-hospital medical detoxification
• Outpatient opioid treatment (after initial 90 days once per fiscal year)
• Peer-support services (24 visits allowed in a fiscal year)
• Professional treatment services in facility-based crisis programs (following the initial seven days/168 units)
• Psychiatric in-patient hospitalization including Institution for Mental Disease (IMD)
• Psychological testing (following the 16 unmanaged outpatient visits (age 21 and under) and eight unmanaged outpatient visits (age 21 and over) in a fiscal year (inclusive of assessment and Psychological Testing codes).
• Substance Abuse Comprehensive Outpatient Treatment (following 60 calendar days of service)
• Substance Abuse Intensive Outpatient Treatment (following 30 calendar days of service)

No referral or authorization is required for a mental health or substance dependence assessment.

• Diagnostic assessment
• Medication assisted treatment (MAT)
• Outpatient behavioral health psychotherapy
• Psychiatric and substance use disorder outpatient and medication management services
• Adult (aged 21 and over) benefit limitation is eight units per state fiscal year.
• Children and adolescents (under age 21) requiring more than 16 units per state fiscal year will require a prior authorization.

• All out-of-network services except emergency services.
• Ambulatory detoxification
• Behavioral health partial hospitalization
• Medically supervised alcohol or drug abuse treatment center detoxification crisis stabilization/ADATC (following first eight hours or one business day of admission)
• Electroconvulsive therapy (ECT)
• Mobile crisis management (for units beyond the initial 32)
• Non-hospital medical detoxification
• Outpatient opioid treatment (after initial 90 days once per fiscal year)
• Peer-support services (24 visits allowed in a fiscal year)
• Professional treatment services in facility-based crisis programs (following the initial seven days/168 units)
• Psychiatric in-patient hospitalization including Institution for Mental Disease (IMD)
• Psychological testing (following the 16 unmanaged outpatient visits (age 21 and under) and eight unmanaged outpatient visits (age 21 and over) in a fiscal year (inclusive of assessment and Psychological Testing codes).
• Substance Abuse Comprehensive Outpatient Treatment (following 60 calendar days of service)
• Substance Abuse Intensive Outpatient Treatment (following 30 calendar days of service)

Each ACNC child member (ages 20 and under) may receive up to 72 total occupational therapy visits during each calendar year without prior authorization. Prior authorization is required following the member’s 72^nd visit to any occupational therapy provider in a calendar year.

Each ACNC adult member (age 21 and over) may receive up to 27 total occupational therapy visits during each calendar year without prior authorization. Prior authorization is required following the member’s 27^th visit to any occupational therapy provider in a calendar year.

Request prior authorization for occupational therapy services from ACNC Utilization Management, 24 hours a day, seven days a week. Please refer to the prior authorization submission process (under How to Submit Prior Authorizations).

A member does not need authorization to see a primary care provider, go to a local health department, or receive services at school-based clinics. In addition, a member does not need authorization for the following services or items:

• Emergency room services (in-network and out-of-network)
• 30-hour observations (except for maternity — see Physical health services that require notification)
• Low-level plain films — X-rays, EKG’s
• Family planning services
• Post-stabilization services (in-network and out-of-network)
• Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screening services
• Women’s health care by in-network providers (OB-GYN services)
• Routine vision services
• Dialysis
• Post-operative pain management (must have a surgical procedure on the same date of service)

Providers are asked to notify ACNC within one business day of when the following services are delivered:

• All newborn deliveries, including those that occur in birthing centers
• Maternity obstetrical services (after first visit) and outpatient care (includes observation)
• Continuation of covered services for a new member transitioning to ACNC during the first 90 calendar days of enrollment
• Inpatient admissions following emergency room medical care, emergency short procedure unit services, or an observation stay

How to submit a notification

• The fastest way to submit medical prior authorizations is electronically, via Medical Authorizations in NaviNet.
  • Medical Authorizations Participant Guide (PDF)
  • Medical Authorizations Frequently Asked Questions (PDF)
• Fax a completed Delivery Notification Form (PDF) to 1-833-893-2262.

Each ACNC child member (ages 20 and under) may receive up to 72 total physical therapy visits during each calendar year without prior authorization. Prior authorization is required following the member’s 72^nd visit to any physical therapy provider in a calendar year.

Each ACNC adult member (age 21 and over) may receive up to 27 total physical therapy visits during each calendar year without prior authorization. Prior authorization is required following the member’s 27^th visit to any physical therapy provider in a calendar year.

Request prior authorization from ACNC Utilization Management, 24 hours a day, seven days a week. Please refer to the prior authorization submission process (under How to Submit Prior Authorizations).

We are rebranding Utilization Management (UM) correspondence from the legacy NIA branding to our new Evolent Branding (PDF).

Codes requiring authorization are listed in the Evolent (formerly known as NIA) Radiology ACNC Utilization Review Matrix (PDF). Use the Prior Authorization Lookup tool for immediate guidance.

To request prior authorization, contact ACNC's radiology benefits vendor, Evolent, via their provider web portal at any time or by calling 1-800-424-4953, Monday through Friday, 8 a.m. to 8 p.m. ET.

Emergency room, observation care and inpatient imaging procedures do not require prior authorization.  

The ordering physician is responsible for obtaining a prior authorization number for the requested radiology service. Patient symptoms, past clinical history and prior treatment information will be requested by Evolent, and the ordering physician should have this information available at the time of the call.

Each ACNC child member (ages 20 and under) may receive up to 72 total speech therapy visits during each calendar year without prior authorization. Prior authorization is required following the member’s 72^nd visit to any speech therapy provider in a calendar year.

Each ACNC adult member (age 21 and over) may receive up to 27 total speech therapy visits during each calendar year without prior authorization. Prior authorization is required following the member’s 27^th visit to any speech therapy provider in a calendar year.

Request prior authorization from ACNC Utilization Management, 24 hours a day, seven days a week. Please refer to the prior authorization submission process (under How to Submit Prior Authorizations).