Prior Authorization
Prior Authorization Lookup Tool
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 below. To submit a request for prior authorization providers may:
Medical services (excluding certain radiology – see below):
- Call the prior authorization line at 1-833-637-3386.
- Complete one of the following forms and fax to 1-833-329-8601:
- You may also submit a prior authorization request via NaviNet.
Behavioral health services:
- Call 1-833-727-3301
- Complete one of the following forms and fax to 1-866-329-3324:
Radiological Services:
- For the following nonemergent outpatient radiological procedures contact National Imaging Associates, Inc. (NIA) at 1-800-424-1665 or visit www.radmd.com:
- CT/CTA
- CCTA
- MRI/MRA
- PET Scan
- Myocardial Perfusion Imaging
- MUGA 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 electronically, please submit an Electronic Prior Authorization (ePA) through your Electronic Health Record (EHR) tool software, or you can submit through any of the following online portals:
If the request is denied, you can request an appeal on the member's behalf by completing the following:
- Request for Redetermination of Medicare Prescription Drug Denial Form PDF
- Request for Redetermination of Medicare Prescription Drug Denial Form - Online
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 out of network services (excluding emergency services)
- All in-patient 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 NIA):
- CT scan
- PET scan
- MRI
- MRA
- MRS
- SPECT scan
- Nuclear cardiac imaging
- Ambulance:
- Elective/non-emergent 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 more than $500 in total billed charges
- Prosthetics and orthotics more than $500 in total billed charges
- The purchase of all wheelchairs (motorized and manual) and all wheelchair accessories (components) regardless of cost per item
- 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