Prior Authorization

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.
• 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.
• 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)

• Elective/Non-Emergent 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
  • 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
  • Certain outpatient diagnostic tests
• Therapy and related services
• Speech therapy, occupational therapy, and physical therapy provided in the home or in an outpatient setting, after the first visit per therapy discipline/type
• Cardiac rehabilitation
• Transplants, including transplant evaluations
• All DME rentals and rent to purchase items
• DME/medical supply/prosthetic device purchases
  • 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
  • Nutritional Supplement
• Hyperbaric oxygen
• Surgery (including sleep apnea/uvulopalatopharyngoplasty (UPPP)
• Religious Non-Medical Health Care Institutions (RNHCI)
• Medications: All infusion/injectable medications listed on the Medicare Professional Fee Schedule with billed amounts of $250 or greater (infusion/injectable medications not listed on the Medicare Professional Fee Schedule are not covered by AmeriHealth VIP Care Plus)
• 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
• Cochlear implantation
• Gastric bypass/vertical band gastroplasty
• Hysterectomy
• Pain management – external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and injections/nerve blocks
• Radiology outpatient services:
  • CT Scan
  • PET Scan
  • MRI
  • MRA
  • MRS
  • SPECT scan
  • Nuclear Cardiac Imaging
• 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 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.