Prior Authorization
Prior authorization is required for all services provided by non-participating physicians and providers, with the exception of emergency services. Prior authorization is also required for other services such as those listed here:
Medical services (excluding certain radiology services)
To submit a request for prior authorization, providers may:
- Call the prior authorization line at 1-855-468-2255.
- Complete one of the following forms and fax it to 1-855-329-6400:
- You may also submit a prior authorization request via NaviNet.
Behavioral health services
Behavioral health service requests should be called into the associated prepaid inpatient health plan (PIHP):
- Wayne County: 1-800-241-4949 (24/7 Crisis Line: 1-800-241-4949)
- Macomb County: 1-855-996-2264 (24/7 Crisis Line: 1-855-927-4747)
Radiological services
For the following non-emergent outpatient radiological procedures, contact Evolent at 1-800-424-4922 or visit RadMD.com:
- CCTA
- CT/CTA
- MRI/MRA
- MUGA scan
- Myocardial perfusion imaging (MPI)
- PET scan
Pharmacy services
For prescription drugs not found on our formulary, an exception can be requested by completing the following:
- Request for Medicare Prescription Drug Coverage Determination Form (PDF)
- To submit the form electronically, please submit an electronic prior authorization (ePA) through your electronic health record (EHR) tool software, or you can it submit through either of the following online portals:
If the request is denied, you can request an appeal on the member's behalf by completing the Request for Redetermination of Medicare Prescription Drug Denial Form (PDF).
Please remember to submit all relevant clinical documentation to support the requested services/items at the time of your request.
Services that require prior authorization by AmeriHealth Caritas VIP Care
All requests for services are subject to Medicare coverage guidelines and limitations.
- All out-of-network services (excluding emergency services)
- All inpatient hospital admissions, including medical, surgical, skilled nursing, and rehabilitation
- Elective transfers for inpatient and/or outpatient services between acute care facilities
- Inpatient services
- Surgery
- 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
- Gastric bypass/vertical band gastroplasty
- Transplants, including transplant evaluations
- Certain outpatient diagnostic tests
- Radiology outpatient services (authorized by Evolent):
- CT scan
- PET scan
- MRI
- MRA
- MRS
- SPECT scan
- Nuclear cardiac imaging
- Ambulance:
- Elective/nonemergent air ambulance transportation
- Certain types of scheduled, nonemergency ambulance trips
- Home health
- Cardiac and pulmonary rehabilitation
- Speech therapy, occupational therapy*, and physical therapy* provided in home or outpatient setting, after the first visit, per therapy discipline/type
- Durable medical equipment (DME):
- All DME rentals and rent-to-purchase items
- Purchase of all items in excess of $750* in total billed charges
- Prosthetics and orthotics in excess of $750* in total billed charges
- The purchase of all wheelchairs (motorized and manual) and all wheelchair accessories (components), regardless of cost per item
*As we continue to reduce the number of items that require prior authorization, some items that are more than $750 in billed charges will no longer require prior authorization. Please refer to the Prior Authorization Lookup Tool to determine if authorization is required.
- Medications: 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
- Pain management — external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, and injections/nerve blocks
- Nutritional supplements
- Hyperbaric oxygen
- Religious Non-Medical Health Care Institutions (RNHCI)
- All "miscellaneous", "unlisted", or "not otherwise specified" codes
- All services that may be considered experimental and/or investigational
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