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Prior Authorization

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

Services that require prior authorization by AmeriHealth Caritas VIP Care Plus (Medicare-Medicaid plan)*

  • Elective or nonemergent air ambulance transportation.
  • All out-of-network services (excluding emergency services).
  • In-patient services:
    • All in-patient hospital admissions, including medical, surgical, skilled nursing, and rehabilitation services.
    • Inpatient diabetes programs and supplies.
    • In-patient medical detoxification.
    • Elective transfers for inpatient and/or outpatient services between acute care facilities.
  • Outpatient mental health care (provided by the PIHP) .
  • Certain outpatient diagnostic tests.
  • 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 rehabilitation.
  • Transplants, including transplant evaluations.
  • Medicare-covered durable medical equipment (DME) items over $500 for purchase and all rental items.
  • Medicare-covered prosthetics and orthotics in excess of $500 for purchase and all rental items.
  • The purchase of all wheelchairs (motorized and manual) and all wheelchair accessories (components), regardless of cost per item.
  • Nutritional supplements.
  • Hyperbaric oxygen.
  • Surgery for sleep apnea (uvulopalatopharyngoplasty [UPPP]).
  • Religious non-medical health care institutions (RNHCIs).
  • Surgical services that may be considered cosmetic, including but not limited to:
    • Blepharoplasty.
    • Mastectomy for gynecomastia.
    • Mastopexy.
    • Maxillofacial.
    • 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.
    • Magnetic resonance angiography.
    • Magnetic resonance spectroscopy.
    • 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 or investigational.
  • All Behavioral Health requests should be called into the associated PIHP:
    • Wayne County: 800-241-4949 (24/7 Crisis Line 800-241-4969).
    • Macomb County: 855-996-2264 (24/7 Crisis Line 800-273-8255).

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

Prior authorization is not required for the following services

  • Non-emergency ambulance requests to or from a facility.
  • Emergency and post-stabilization services, including emergency behavioral health care, urgent care, low-level plain X-rays, electrocardiograms (EKGs), crisis stabilization (including mental health), family planning services, preventive services, communicable disease services (including sexually transmitted infection [STI] and HIV testing), post-stabilization care services (in and out of network), and out-of-area renal dialysis services.

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