Amerihealth Caritas Prior Authorization Form Requirements and Process

To obtain prior authorization from AmeriHealth Caritas, you'll need to submit a completed prior authorization form.

The form typically requires information about the patient, including their name, date of birth, and medical record number.

You'll also need to provide details about the requested treatment or service, such as the diagnosis, procedure code, and number of units or sessions.

The prior authorization form must be signed by the treating physician or other authorized healthcare provider.

AmeriHealth Caritas reviews the form and supporting documentation to determine medical necessity and coverage.

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To request services through AmeriHealth Caritas, you need to submit a prior authorization request to the Utilization Management (UM) department. The UM department hours of operation are 8 a.m. – 5:30 p.m., Monday through Friday.

You can submit requests through NaviNet, by telephone at 202-408-4823 or 1-800-408-7510, or by fax at 202-408-1031 or 1-877-759-6216. For Behavioral Health Utilization Management, you can contact them directly at 1-877-464-2911 or email [email protected].

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Some services require prior authorization review for medical necessity and place of service, including elective or non-emergent air ambulance transportation, all out-of-network services, and inpatient services.

To facilitate the prior authorization process, you'll need to provide specific information, including the member's Plan ID number, name, date of birth, diagnosis/diagnoses codes (ICD-10), requested CPT codes, date of service, ordering/referring doctor NPI, facility/treating provider NPI, and applicable clinical information.

Here are some services that require prior authorization review for medical necessity and place of service:

AmeriHealth Caritas has made it easier for providers to submit prior authorizations electronically. This means you can skip the hassle of paperwork and faxing.

You can access the Medical Authorizations portal through NaviNet, located on the Workflows menu. This portal allows you to submit and inquire on existing authorizations, making it a one-stop-shop for all your prior authorization needs.

In addition to submitting and inquiring on existing authorizations, you can also verify if no authorization is required, which can save you time and effort. Auto approvals are also available in some circumstances, making the process even smoother.

You can submit amended authorizations, attach supplemental documentation, and even sign up for in-app status change notifications directly from the health plan. This keeps you informed and up-to-date on the status of your prior authorization requests.

Here are some of the key benefits of using the Medical Authorizations portal:

If you're looking to navigate the AmeriHealth Caritas prior authorization form, here are some key points to keep in mind. You can submit requests online, by phone, or by mail, but be aware that the processing time can take up to 5 business days.

AmeriHealth Caritas requires prior authorization for certain services, including certain medications, durable medical equipment, and other treatments. This is to ensure that the services are medically necessary and align with the patient's treatment plan.

To expedite the process, it's a good idea to gather all necessary documentation before submitting the request. This may include medical records, test results, and other relevant information.

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If you're a rendering network provider, you need to have a valid Pennsylvania Medical Assistance (MA) Provider ID to get reimbursed for your services. This is a mandatory requirement.

As of January 1, 2018, any claim submitted by rendering network providers subject to the ordering/referring/prescribing (ORP) requirement will be denied if it's billed with the NPI of an ORP provider who isn't enrolled in MA. This means you need to make sure you're enrolled in MA to avoid denied claims.

To check the MA enrollment status of the practitioner ordering, referring, or prescribing the service you're providing, visit the DHS provider look-up portal.

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Many medicines have specific requirements and conditions that must be met to receive prior authorization, so it's a good idea to check the list of medications and their prior authorization criteria before submitting your request.

Some medications require prior authorization, and it's essential to review the criteria for each one to avoid delays in receiving the medication you need.

To request prior authorization, you can submit a request to the Utilization Management (UM) department. They're available Monday through Friday from 8 a.m. to 5:30 p.m.

You can submit requests through NaviNet, or by calling 202-408-4823 or 1-800-408-7510. You can also fax your request to 202-408-1031 or 1-877-759-6216.

If you need to contact the Behavioral Health Utilization Management team directly, call 1-877-464-2911 or email [email protected].

Some services, like radiology, have a separate process for prior authorization. For those, you'll need to contact Evolent at 1-877-517-9177 or visit www.radmd.com.

To submit a prior authorization request, you'll need to have the following information ready: