Most prior authorization for surgeries for Medicaid participants are provided through Qualis Health. Procedures requiring prior authorization through Qualis are listed in the Qualis Provider Manual. 

The Medical Care Unit reviews and provides prior authorization for a small number of surgeries and other procedures as identified in the IdahoMedicaidHospital and Physician Provider Handbooks. The numeric fee schedule provides more specific information on reimbursement for procedures and requirements for prior authorization listed by current procedural terminology (CPT) code.  

To receive authorization for a surgery: 

• Fax a fully completed surgery prior authorization request form to the Medical Care Unit at (208) 332-7280, along with all pertinent records: history and physical, treatment plan, records of consultations, history of disease, provider and/or surgeon notes, and information on the participant’s present condition.
•  The nurse reviewer may request additional documentation to establish medical necessity for the procedure. The requested documentation must be received by the Medical Care Unit within seven working days or the request will be denied, unless another date has been agreed upon by the nurse reviewer and the requesting provider. 
• If the surgery is urgent, the nurse reviewer will contact the provider to notify them of the result of the review.  Providers should contact Medicaid fiscal contractor EDS at (800) 685-3757 to check on the status of routine requests.

Most reviews are completed within one business day once all requested information is received. Complex requests requiring review by the Medical Director may take additional time.   
For more information contact (208) 364-1954.