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.
- For outlier days beyond original DRG approval requests, please complete the Clinical Review for Outlier Days to Original DRG Approval Request Form (PDF).
- 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:
- Mastectomy for gynecomastia
- Penile prosthesis
- Plastic surgery/cosmetic dermatology
- Reduction mammoplasty
- Cochlear implantation
- Gastric bypass/vertical band gastroplasty
- Pain management – external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and injections/nerve blocks
- Radiology outpatient services:
- CT Scan
- PET Scan
- 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.