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):

Behavioral health services:

Radiological Services:

  • For the following non-emergent outpatient radiological procedures contact National Imaging Associates, Inc. (NIA) at 1-800-424-4922 or visit
    • 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:

If the request is denied, you can request an appeal on the member’s behalf by completing the following:

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