Prior Authorization

Prior authorization is required to see out-of-network providers, with the exception of emergency services. To submit a request for prior authorization providers may:

  • Call the prior authorization line at 1-833-435-8686 (*for behavioral health requests call 1-833-727-3598);
  • Have your provider fill out this form for prior authorization requests (PDF) and fax it to 1-833-329-3586 (for behavioral health requests, fax to 1-866-329-3324).

Services that require prior authorization by AmeriHealth Caritas VIP Care (HMO-SNP)*

  • Elective or nonemergent air ambulance transportation.
  • All out-of-network services (excluding emergency services).
  • Inpatient services:
    • All inpatient hospital admissions, including medical, surgical, skilled nursing, and rehabilitation.
    • Obstetrical admissions and newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after Caesarean sections.
    • Inpatient diabetes programs and supplies.
    • Inpatient 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 a home or outpatient setting after the first visit per therapy discipline or type.
    • Cardiac and pulmonary rehabilitation.
  • Transplants, including transplant evaluations.
  • All durable medical equipment (DME) rentals and rent-to-purchase items.
  • DME, medical supply, and prosthetic device purchases.
  • Hyperbaric oxygen.
  • Religious nonmedical health care institutions (RNHCIs).
  • Medications: 17-P and all infusion or injectable medications listed on the Medicare Professional Fee Schedule; infusion or 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 surgery.
    • Panniculectomy.
    • Penile prosthesis.
    • Plastic surgery or cosmetic dermatology.
    • Reduction mammoplasty.
    • Septoplasty.
  • Cochlear implantation.
  • Gastric bypass or vertical band gastroplasty.
  • Hysterectomy.
  • Pain management — external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and injections or nerve blocks.
  • Radiology outpatient services:
    • Computed tomography (CT) scan.
    • Positron emission tomography (PET) scan.
    • Magnetic resonance imaging (MRI).
    • Magnetic resonance angiography (MRA).
    • Magnetic resonance spectroscopy (MRS).
    • Single-photon emission computed tomography (SPECT) scan.
    • Nuclear cardiac imaging.
  • All miscellaneous, unlisted, or not otherwise specified codes.
  • All services that may be considered experimental and/or investigational.

*All requests for services are subject to Medicare coverage guidelines and limitations.

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