Prior Authorization

Prior authorization is required to see out-of-network providers, with the exception of emergency services. To submit a request for prior authorization providers may:

• Call the prior authorization line at 1-855-294-7046 (*for behavioral health requests call 1-866-588-0219);
• Have your provider fill out this form for prior authorization requests (PDF) and fax it to 1-855-859-4111 (for behavioral health requests, fax to 1-855-396-5750).

Services that require prior authorization by AmeriHealth Caritas VIP Care (HMO-SNP)*

• Elective or non-emergent air ambulance transportation
• All out-of-network services (excluding emergency services)
• Inpatient services:
  • All inpatient hospital admissions, including medical, surgical, skilled nursing, and rehabilitation
  • Obstetrical admissions and newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after Caesarean sections
  • Inpatient diabetes programs and supplies
  • Inpatient medical detoxification
  • Elective transfers for inpatient and/or outpatient services between acute care facilities
• Certain outpatient diagnostic tests
• Home health
• Therapy and related services:
  • Speech therapy, occupational therapy, and physical therapy provided in a home or outpatient setting after the first visit per therapy discipline or type
  • Cardiac and pulmonary rehabilitation
• Transplants, including transplant evaluations
• All durable medical equipment (DME) rentals and rent-to-purchase items
• DME, medical supply, and prosthetic device purchases.
• Hyperbaric oxygen
• Religious nonmedical health care institutions (RNHCIs)
• Medications: 17-P and all infusion or injectable medications listed on the Medicare Professional Fee Schedule; infusion or injectable medications not listed on the Medicare Professional Fee Schedule are not covered by AmeriHealth Caritas VIP Care
• Surgical services that may be considered cosmetic, including but not limited to:
  • Blepharoplasty
  • Mastectomy for gynecomastia
  • Mastopexy
  • Maxillofacial surgery
  • Panniculectomy
  • Penile prosthesis
  • Plastic surgery or cosmetic dermatology
  • Reduction mammoplasty
  • Septoplasty
• Cochlear implantation
• Gastric bypass or vertical band gastroplasty
• Hysterectomy
• Pain management — external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and injections or nerve blocks
• Radiology outpatient services:
  • Computed tomography (CT) scan
  • Positron emission tomography (PET) scan
  • Magnetic resonance imaging (MRI)
  • Magnetic resonance angiography (MRA)
  • Magnetic resonance spectroscopy (MRS)
  • Single-photon emission computed tomography (SPECT) scan
  • Nuclear cardiac imaging
• All miscellaneous, unlisted, or not otherwise specified codes
• All services that may be considered experimental and/or investigational

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