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:
- Call the prior authorization line at 1-866-263-9011.
- Complete the prior authorization form (PDF) and fax it to 1-866-263-9036.
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:
- Mastectomy for gynecomastia.
- Penile prosthesis.
- Plastic surgery or cosmetic dermatology.
- Reduction mammoplasty.
- Cochlear implantation.
- Gastric bypass or vertical band gastroplasty.
- 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.