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:

• Call the prior authorization line at 1-855-294-7046.
• Complete the prior authorization form (PDF) or the skilled nursing facilities prior authorization form (PDF) and fax it to 1-855-859-4111.
• For behavioral health prior authorizations, follow these easy steps.
• You may also submit a prior authorization request via NaviNet.
• 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

• 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.