Benefits
Benefit Grids
The Benefit Grids include service codes, service limits, level of care and documentation requirements for service authorization requests. They also include requirements for unmanaged services.
- Behavioral Health Medicaid and State Benefit Grids (.xlsx) (enable editing to use filters)
- Tailored Plan Physical Health Services that Require Prior Authorization
- Medicaid Direct and Medicaid Managed Care Covered Procedure Codes
CMS-Approved Non-Quantitative Treatment Limitations
The North Carolina Department of Health and Human Services approved Non-Quantitative Treatment Limitations that maintain compliance with the Mental Health Parity and Addiction Equity Act.
Prior Authorization
Vaya Partners Authorization Guidelines
Services Managed by Other Organizations
Some services are managed by organizations outside of Partners. Use the information below to find the right place for help.
| Organization | Services managed | Provider information |
|---|---|---|
| Envolve Vision | Vision services | Envolve Vision |
| NC Medicaid | Dental services | NC Medicaid |
| Evolent | Advanced imaging Musculoskeletal surgery Interventional pain management Radiation oncology |
Providers may use RadMD for advanced imaging, musculoskeletal surgery and interventional pain management requests.
Radiation oncology requests are submitted through Evolent’s CarePro portal. Evolent lists CarePro and RadMD through its provider portal. |
| EviCore | Genetic testing | Providers may use EviCore’s Provider’s Hub for prior authorization resources. |
Pharmacy prior authorizations
Visit the Pharmacy/Medication Prior Authorization page for more information.
Non-participating/out-of-network providers must submit Prior Authorization for all services.
Prior Authorization Lookup Tool
Partners’ Prior Authorization (PA) Lookup Tool provides authorization requirements by service code. We have made every attempt to ensure the most current information is included in the PA Lookup Tool. However, use of this tool does not guarantee payment. It is the provider’s responsibility to ensure proper eligibility, coverage benefits, provider contracts, correct coding and billing practices are followed. You may also refer to the Partners Benefit Grids and enter an authorization request into ProAuth if prior authorization is indicated.
Search for all codes that require approval.
Enter the base code of the service you would like to check, and then select a mod: