Understanding AmeriHealth Caritas Prior Authorization Requirements

To navigate the prior authorization process with AmeriHealth Caritas, it's essential to understand the requirements.

AmeriHealth Caritas has a comprehensive prior authorization process that varies depending on the service or medication.

The process typically begins with a request from your healthcare provider to AmeriHealth Caritas.

Your provider will need to provide detailed information about your medical condition, treatment plan, and the requested service or medication.

AmeriHealth Caritas will review your request and may request additional information before making a decision.

The review process typically takes 24-48 hours, but can vary depending on the complexity of the case.

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The prior authorization process can be a bit complex, but it's designed to ensure that you get the care you need. Your primary care physician or other healthcare provider must give AmeriHealth Caritas Pennsylvania information to show that a service or medication is medically necessary.

AmeriHealth Caritas Pennsylvania nurses or pharmacists review this information, using clinical guidelines approved by the Department of Human Services to determine if the service or medicine is medically necessary. This is a crucial step in the process, as it helps ensure that you're getting the right care at the right time.

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If the request can't be approved by an AmeriHealth Caritas Pennsylvania nurse or pharmacist, an AmeriHealth Caritas Pennsylvania doctor will review the request. This adds an extra layer of expertise to the process, helping to ensure that your needs are met.

If your request is approved, you and your healthcare provider will be notified. If your request is not approved, a letter will be sent to you and your healthcare provider explaining the reason for the decision.

Here are the steps involved in the prior authorization process:

If you're not satisfied with the decision, you can file a complaint or grievance and/or request a fair hearing. You can also call Member Services for help with this process.

Services requiring prior authorization can be a bit confusing, but let's break it down. Elective or non-emergent air ambulance transportation requires prior authorization review for medical necessity and place of service.

Some services are excluded from coverage altogether, like elective transfers for inpatient and/or outpatient services between acute care facilities, or transplants that must be approved by DC Medicaid fee-for-service (FFS). Transplants are excluded from coverage for AmeriHealth Caritas DC Alliance enrollees.

Here are some specific services that require prior authorization:

Elective air ambulance transportation requires prior authorization review for medical necessity and place of service.

All out-of-network services, excluding emergency services, also need prior authorization.

Some services that may be considered experimental or investigational require prior authorization, including all services not listed on the Ohio Department of Medicaid Fee Schedule.

Unlisted miscellaneous and manually priced codes, including those ending in "99", also require prior authorization.

All inpatient hospital admissions, including medical, surgical, skilled nursing, long-term acute, and rehabilitation services need prior authorization.

Obstetrical admissions, newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after cesarean section require prior authorization.

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Elective transfers for inpatient and/or outpatient services between acute care facilities also need prior authorization.

Long-term care initial placement, while enrolled with the plan, up to 90 days requires prior authorization.

Chiropractic care requires prior authorization for members under age 18.

Durable medical equipment (DME) rentals, leases, and custom equipment, as well as DME with billed charges over $750, require prior authorization.

Here is a list of services that may be considered cosmetic and require prior authorization:

Note: The following radiology services require prior authorization when performed as an outpatient service:

These services are subject to change, so it's essential to check with your healthcare provider or insurance company for the most up-to-date information.

Behavioral health services often require prior authorization, especially for certain types of treatments.

Adult inpatient hospitalizations for mental health and/or substance use disorder require prior authorization. This applies to individuals 21 years and older.

Psychological and neuropsychological testing, as well as electroconvulsive therapy, also need prior authorization.

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Therapeutic Group Services, including Day Treatment Per Diem, require prior authorization. Assertive Community Treatment is another service that needs prior authorization.

Applied Behavioral Analysis Therapy for Autism Spectrum Disorder and Substance Use Disorder Partial Hospitalization Program (ASAM 2.5) also require prior authorization.

Substance Use Disorder Residential Treatment (ASAM 3.1, 3.5, 3.7) needs prior authorization as well.

If you're admitted to a hospital for behavioral health services 31 or more days during either admission, you'll need prior authorization and a medical necessity review.

Similarly, third and subsequent admissions in a calendar year for behavioral health services require prior authorization and a medical necessity review.

Unlisted psychiatric services also need prior authorization.

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To navigate the prior authorization process with AmeriHealth Caritas, it's essential to understand the access and criteria involved.

Many medicines have specific requirements and conditions that must be met to receive prior authorization. You can save time by viewing a list of medications and their prior authorization criteria before submitting your request.

AmeriHealth Caritas provides a list of medications and their prior authorization criteria that you can access and review. This list is available in PDF format.

To ensure a smooth prior authorization process, it's crucial to meet the specific requirements and conditions for each medication.

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AmeriHealth Caritas has made some changes to their prior authorization process, and it's essential to know what to expect. As of January 12, 2024, AmeriHealth Caritas DC will be the single point of contact for all new prior authorization requests.

This means that eviCore healthcare will no longer be handling these requests. If you need to check the status of a prior authorization, you can use the prior authorization lookup tool.

The following services always require prior authorization: elective inpatient services, urgent inpatient services, and services from a non-participating provider.

To get specialty prior authorization forms, you can visit the AmeriHealth Caritas website. You can also complete the medical prior authorization form, which is available as a PDF.

It's worth noting that prior authorization requirements can change, so it's a good idea to check the provider manual (PDF) for the most up-to-date information.

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For AmeriHealth Caritas prior authorization, you can find forms and resources on their website.

To start the prior authorization process, you'll need to submit a Prior Authorization Request Form, which can be downloaded from the AmeriHealth Caritas website.

You can also contact their customer service department to request a form by phone or mail.

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With AmeriHealth Caritas District of Columbia, you can now submit medical authorizations electronically through NaviNet.

You can verify if no authorization is required, which can save you time and hassle.

Auto approvals are available in some circumstances, making the process even smoother.

You can submit amended authorizations, which is a great feature for when circumstances change.

You can also attach supplemental documentation to support your request.

In-app status change notifications are available, so you'll always be up-to-date on the status of your authorization.

A multi-payer authorization log is accessible, giving you a clear view of all your authorizations in one place.

You can even submit inpatient concurrent reviews online, eliminating the need for faxes.

Here are the benefits of electronic authorization submission:

Drug Class-Specific Forms are available for various medications, and it's essential to use the correct form for your needs. You can find these forms in the article section.

For instance, if you're looking for forms related to antidepressants, antihemophilia agents, antipsychotics, or other specific drug classes, you can find the relevant forms in the article section. Each form is available as a PDF download.

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Here are some examples of drug class-specific forms you can find:

Remember, each form must be completed in its entirety and faxed to 1-855-851-4058.