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.

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