Celtic Insurance Company dba Ambetter Prior Authorization

Celtic Insurance Company dba Ambetter 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

Prior authorization is required for certain services and all out-of-network services except emergency room services in at least some Celtic/Ambetter markets. Official guidance indicates providers should verify requirements using the plan-specific 'Pre-Auth Needed' tool or the provider manual, and requests may be submitted by secure provider portal, fax, or phone depending on state/line of business. For at least one marketplace manual reviewed, all inpatient admissions require prior authorization.
Requirements vary by state and product line; do not assume a single PA rule set for all Ambetter/Celtic products.
The Texas PA page reviewed uses plan-specific phone/fax/portal references and is not necessarily the same for Illinois or other states.
Failure to obtain required prior authorization may result in denial of the claim; some manuals also state associated downstream services do not require separate PA when tied to an authorized procedure.

Where to verify prior authorization requirements

How to submit prior authorization requests

Secure Provider Portal
Fax
Phone
Submission resource 1
Submission resource 2

Information commonly required

Provider NPI
Practice TIN
Member ID
Clinical documentation supporting medical necessity for faxed requests
Completed Authorization Request form when submitting by fax for applicable services

Turnaround notes and caveats

For one reviewed market, non-urgent requests should be initiated before service and it is recommended they be submitted at least 5 business days before the desired start date.
A reviewed manual states retrospective review decisions are made within 30 calendar days of receipt.
If required clinical information is missing, the plan attempts follow-up by phone and may forward the request to a Medical Director based on available information.
Requirements vary by state and product line; do not assume a single PA rule set for all Ambetter/Celtic products.
The Texas PA page reviewed uses plan-specific phone/fax/portal references and is not necessarily the same for Illinois or other states.
Failure to obtain required prior authorization may result in denial of the claim; some manuals also state associated downstream services do not require separate PA when tied to an authorized procedure.

Provider resources

Sources

Fact	Value	Source	Confidence
Illinois manual: services requiring PA / out-of-network rule / downstream services	To verify if a service requires prior authorization, use the Pre-Auth Needed tool or call Utilization Management; all out-of-network services require prior authorization except emergency room services; all inpatient admissions require prior authorization; downstream anesthesiology/pathology/radiology/hospitalist services tied to an authorized procedure do not require separate PA.	Official	high
Texas marketplace PA page: submission methods and info required	Prior authorization requests can be submitted by fax, phone, or secure provider portal; TIN and NPI that will be used to bill the claim must be supplied.	Official	high
Florida prior auth update page: operational support	Ambetter Health says providers may contact Provider Services for questions about PA changes and references provider resources/manuals for specific code requirements.	Official	medium

Last reviewed: March 27, 2026

Sources used: 3 official