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 1-855-294-7046 (*for behavioral health requests call 1-866-588-0219)
  • Have your provider fill out this form for prior authorization requests (PDF) and fax it to 1-855-859-4111 (for behavioral health requests, fax to 1-855-396-5750).

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

  • Elective or non-emergent 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. Prior authorization and limits may apply for some comprehensive dental services.

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