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

Home Health Services (contact tango)

  • Call 1-888-705-5274
  • Provider Portal – ProNet Connect

Radiological services

  • For the following non-emergent outpatient radiological procedures contact Evolent at 1-800-424-4922 or visit www1.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:

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

  • All out-of-network services (excluding emergency services)
  • All inpatient 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 Evolent):
    • CT scan
    • PET scan
    • MRI
    • MRA
    • MRS
    • SPECT scan
    • Nuclear cardiac imaging
  • Ambulance:
    • Elective/nonemergent 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 in excess of $750* in total billed charges
    • Prosthetics and orthotics in excess of $750* in total billed charges
    • The purchase of all wheelchairs (motorized and manual) and all wheelchair accessories (components), regardless of cost per item

*As we continue to reduce the number of items that require prior authorization, some items that are more than $750 in billed charges will no longer require prior authorization. Please refer to the Prior Authorization Lookup Tool to determine if authorization is required.

  • 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