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.
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