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 non-emergent air ambulance transportation
  • All out-of-network services (excluding emergency services)
  • Inpatient services in a psychiatric hospital
  • Partial Hospitalization
  • Outpatient mental health care (provided by the PIHP)
  • Certain outpatient diagnostic tests
  • Transplants, including transplant evaluations
  • Medicare-covered durable medical equipment (DME) items
  • Medicare-covered prosthetics and orthotics
  • 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: 1-800-241-4949 (24/7 Crisis Line 1-800-241-4949)
    • Macomb County: 1-855-996-2264 (24/7 Crisis Line 1-855-927-4747)

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

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