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.