Prior Authorization

Prior Authorization Lookup Tool

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. *Please see bullet below for prior authorization instructions for specified outpatient radiological procedures.
• 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.
• For outlier days beyond original DRG approval requests, please complete the Clinical Review for Outlier Days to Original DRG Approval Request Form PDF.
• For the following non-emergent outpatient radiological procedures contact National Imaging Associates, Inc. (NIA) at 1-866-272-4085 or visit www.radmd.com:
  • • CT/CTA
    • CCTA
    • MRI/MRA
    • PET Scan
    • Myocardial Perfusion Imaging
    • MUGA Scan
• 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)**

• All out-of-network services (excluding emergency services).
• All inpatient hospital admissions, including medical, surgical, skilled nursing, and rehabilitation.
• Elective transfers for inpatient and/or outpatient services between acute care facilities.
• Inpatient services.
• Surgery.
• 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.
  • Gastric bypass/vertical band gastroplasty.
• Transplants, including transplant evaluations.
• Certain outpatient diagnostic tests.
• Radiology outpatient services (authorized by NIA):
• • CT scan.
  • PET scan.
  • MRI.
  • MRA.
  • MRS.
  • SPECT scan.
  • Nuclear cardiac imaging.
• Ambulance:
• • Elective/nonemergent air ambulance transportation.
  • Certain types of scheduled, nonemergency ambulance trips.
• Home health.
• Cardiac and pulmonary rehabilitation.
• Speech therapy, occupational therapy, and physical therapy provided in home or outpatient setting, after the first visit, per therapy discipline/type.
• Durable medical equipment (DME):
• • All DME rentals and rent-to-purchase items.
  • 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.
• Medications: All infusion/injectable medications listed on the Medicare Professional Fee Schedule — infusion/injectable medications not listed on the Medicare Professional Fee Schedule are not covered.
• Pain management — external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, and injections/nerve blocks,
• Nutritional supplements.
• Hyperbaric oxygen.
• Religious Non-Medical Health Care Institutions (RNHCI).
• 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 prepaid inpatient health plan (PIHP):
• • Wayne County: 313-344-9099 (24/7 Crisis Line 1-800-241-4949)
  • Macomb County: 855-996-2264 (24/7 Crisis Line 1-855-927-4747)

**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.