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:

• 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 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.