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 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: 313-344-9099 (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.