Ambetter (Centene) Prior Authorization

Ambetter (Centene) publishes service-specific prior authorization guidance. Start with the payer resource below, then confirm the member's plan and the requested service before care is scheduled or submitted.

At a glance

• Ambetter generally requires prior authorization for non-urgent services before the service is delivered, with submission available through the Secure Provider Portal and, depending on state/line of business, by fax and/or phone. The exact workflow, fax numbers, and service-specific requirements vary by state plan; Ambetter also directs providers to use its 'Pre-Auth Needed' tool to check whether authorization is required.
• Prior authorization rules are not uniform across all Ambetter plans; fax numbers, phone numbers, and even whether phone/fax is offered differ by state.
• Emergency services and some inpatient stabilization scenarios may not require prior authorization, but state-specific manuals should be checked.
• This research did not identify a single Ambetter-wide provider manual covering all states; state manuals/quick reference guides are the operative source.

Where to verify prior authorization requirements

• Verification resource 1
• Verification resource 2
• Verification resource 3

How to submit prior authorization requests

• Secure Provider Portal

• Fax

• Phone

• Submission resource 1

Information commonly required

• TIN and NPI used to bill the claim after the authorized service is provided
• member and service information sufficient to determine medical necessity and service type
• state-specific authorization form / fax form when required

Turnaround notes and caveats

• Ambetter’s Texas marketplace page recommends submitting non-urgent prior authorization requests at least 5 business days before the desired start date of service.
• Texas marketplace page states prior authorization assistance is available Monday-Friday 6:00 a.m. to 6:00 p.m. CT, and 9:00 a.m. to noon CT on Saturdays, Sundays, and legal holidays.
• Prior authorization rules are not uniform across all Ambetter plans; fax numbers, phone numbers, and even whether phone/fax is offered differ by state.
• Emergency services and some inpatient stabilization scenarios may not require prior authorization, but state-specific manuals should be checked.
• This research did not identify a single Ambetter-wide provider manual covering all states; state manuals/quick reference guides are the operative source.

Provider resources

• Provider Toolkit: Quick Reference Guide (official)
• Provider Toolkit: Secure Provider Portal (official)
• Provider Toolkit: Prior Authorization Guide (official)
• Prior Authorization Requirements for Health Insurance Marketplace (official)

Sources