Prior Authorization

Prior Authorization Lookup Tool

Except for emergency services, prior authorization is required for certain services (see list below) provided by all providers. The most up to date listing of services requiring Prior Authorization is maintained in the Prior Authorization Lookup Tool.

Prior authorization is not a guarantee of payment. AmeriHealth Caritas VIP Care Plus reserves the right to adjust any payment made following a review of the medical record or other documentation and/or determination of the medical necessity of the services provided.

AmeriHealth Caritas VIP Care Plus has up to 14 calendar days to complete a standard request and 72 hours to complete an expedited request for prior authorization. Once an authorization is processed, the AmeriHealth Caritas VIP Care Plus provider will receive notification via a phone call and a fax alerting them to the organization determination.

Please remember to submit all relevant clinical documentation to support the prior authorization request.

To submit a request for prior authorization providers may:

Medical services

Refer to eviCore instructions below for the following services:

  • Diagnostic Sleep Testing
  • DME
  • Genetic Testing
  • Joint & Spine Surgery
  • Occupational Therapy
  • Pain Management
  • Physical Therapy
  • Radiation Oncology

Refer to NIA instructions below for the following radiological services:

  • CCTA
  • CT/CTA
  • MRI/MRA
  • MUGA Scan
  • Myocardial Perfusion Imaging
  • PET Scan

For all other medical services (utilize one of the following options):

Behavioral health service 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)

eviCore (utilize one of the following options):

  • Log on to evicore.com (preferred) 24 hours, 7 days a week and the quickest way to obtain information.
  • Call: 1-877-506-5193 and fax clinical information along with the case #, member ID, and DOB on each page:
    • Joint and Spine Surgery, Pain Management, Radiation Oncology: 1-800-540-2406
    • Genetic Testing: 1-844-545-9213
    • Sleep testing and Sleep DME: 1-866-999-3510
    • Physical and Occupational Therapy: 1-855-774-1319
    • DME: 1-866-663-7740

National Imaging Associates, Inc. (NIA) Radiological Services (utilize one of the following options):

Pharmacy Services

For prescription drugs not found on our formulary, an exception can be requested by completing one of the following:

If the request is denied, you can request an appeal on the member's behalf by completing the following:

Services that require Prior Authorization by AmeriHealth Caritas VIP Care Plus (Medicare-Medicaid Plan)

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

  • 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 (*OT and PT authorized by eviCore).
  • Durable medical equipment (DME) (authorized by eviCore):
    • All DME rentals and rent-to-purchase items.
    • Purchase of all items in excess of $500 in total billed charges.
    • Prosthetics and orthotics in excess of $500 in total billed 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 (authorized by eviCore).
  • 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.
Providers