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Prior Authorization

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:

  • Call the prior authorization line at 1-866-263-9011.
  • Complete the prior authorization form (PDF) or the skilled nursing facilities (PDF) prior authorization form and fax it to 1-866-263-9036.
  • You may also submit a prior authorization request via NaviNet.
  • 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 Plus (Medicare-Medicaid Plan)

  • Elective/Non-Emergent 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
    • 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
    • Certain outpatient diagnostic tests
  • Therapy and related services
    • Speech therapy, occupational therapy, and physical therapy provided in the home or in an outpatient setting, after the first visit per therapy discipline/type
    • Cardiac rehabilitation
  • Transplants, including transplant evaluations
  • All DME rentals and rent to purchase items
  • DME/medical supply/prosthetic device purchases
    • Purchase of all items in excess of $500 in total allowable charges
    • Prosthetics and orthotics in excess of $500 in total allowable charges
    • The purchase of all wheelchairs (motorized and manual) and all wheelchair accessories (components) regardless of cost per item
    • Nutritional Supplement
  • Hyperbaric oxygen
  • Surgery (including sleep apnea/uvulopalatopharyngoplasty (UPPP)
  • Religious Non-Medical Health Care Institutions (RNHCI)
  • Medications: All infusion/injectable medications listed on the Medicare Professional Fee Schedule with billed amounts of $250 or greater (infusion/injectable medications not listed on the Medicare Professional Fee Schedule are not covered by AmeriHealth VIP Care Plus)
  • 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
  • Cochlear implantation
  • Gastric bypass/vertical band gastroplasty
  • Hysterectomy
  • Pain management – external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and injections/nerve blocks
  • Radiology outpatient services:
    • CT Scan
    • PET Scan
    • MRI
    • MRA
    • MRS
    • SPECT scan
    • Nuclear Cardiac Imaging
  • All miscellaneous/unlisted or not otherwise specified codes
  • All services that may be considered experimental and/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

Emergency and post-stabilization services,  (including emergency behavioral health care); urgent care, low level plain-film, X-rays; EKGs; crisis stabilization, including mental health; family planning services; preventive services; communicable disease services, including STI and HIV testing; post-stabilization care services (in and out of network); and, out-of-area renal dialysis services.

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