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Prior Authorization

Prior authorization is required for all referrals to non-participating physicians and providers, with the exception of emergency services. Prior Authorization is also required for other services such as those listed below. To submit a request for prior authorization providers may:

Services that require Prior Authorization by AmeriHealth Caritas VIP Care

  • Elective/Non-Emergent Air Ambulance Transportation.
  • All out-of-network services (excluding emergency services).
  • In-patient services.
    • All in-patient hospital admissions, including medical, surgical, skilled nursing and rehabilitation.
    • Obstetrical Admissions/Newborn Deliveries exceeding 48 hours after vaginal delivery and 96 hours after caesarean section.
    • Inpatient Diabetes programs and supplies.
    • In-patient Medical Detoxification.
    • Elective transfers for inpatient and/or outpatient services between acute care facilities.
  • Certain outpatient diagnostic tests.
  • Home Health.
  • Therapy and related services.
    • Speech Therapy, Occupational Therapy and Physical Therapy provided in home or outpatient setting, after the first visit per therapy discipline/type.
    • Cardiac and Pulmonary Rehabilitation.
  • Transplants, including transplant evaluations.
  • All DME rentals and rent to purchase items.
  • DME/Medical Supply/Prosthetic Device Purchases. 
    • Medicare-covered DME items over $500 for purchase and rental.
    • Medicare –covered Prosthetics and orthotics over $500.
    • All wheelchairs (motorized and manual) and all wheelchair accessories (components) regardless of cost per item.
  • Hyperbaric Oxygen.
  • Surgery (for sleep apnea/uvulopalatopharyngoplasty (UPPP).
  • Religious Non-Medical Health Care Institutions (RNHCI).
  • Medications: 17-P and all infusion/injectable medications listed on the Medicare Professional Fee Schedule; infusion/injectable medications not listed on the Medicare Professional Fee Schedule are not covered by AmeriHealth Caritas VIP Care.
  • Surgical services that may be considered cosmetic, including but not limited to:
    • Blepharoplasty.
    • Mastectomy for Gynecomastia.
    • Mastopexy.
    • Maxillofacial.
    • Panniculectomy.
    • Penile Prosthesis.
    • Plastic Surgery/Cosmetic Dermatology.
    • Reduction Mammoplasty.
    • Septoplasty.
  • Cochlear Implantation.
  • Gastric Bypass/Vertical Band Gastroplasty.
  • Hysterectomy.
  • Pain Management – external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and injections/nerve blocks.
  • Radiology Outpatient Services:
    • CT Scan.
    • PET Scan.
    • MRI.
    • MRA.
    • MRS.
    • SPECT scan.
    • Nuclear Cardiac Imaging.
  • All miscellaneous/unlisted or not otherwise specified codes.
  • All services that may be considered experimental and/or investigational.

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