Prior Authorization
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 here.
Medical services (excluding certain radiology services)
To submit a request for prior authorization, providers may:
- Call the prior authorization line at 1-877-625-7229.
- Complete one of the following forms and fax it to 1-833-952-7262:
- You may also submit a prior authorization request via NaviNet.
Behavioral health services
- Call 1-855-330-2999.
- Complete one of the following forms and fax it to 1-833-362-7262:
Radiological services
- For the following non-emergent outpatient radiological procedures contact Evolent at 1-800-642-7649 or visit RadMD:
- CCTA
- CT/CTA
- MRI/MRA
- MUGA Scan
- Myocardial perfusion imaging
- PET scan
Pharmacy services
For prescription drugs not found on our formulary, an exception can be requested by completing the following:
- Request for Medicare Prescription Drug Coverage Determination Form (PDF)
- To submit the form electronically, please submit an electronic prior authorization (EPA) through your electronic health record (EHR) tool software, or you can submit through any of the following online portals:
If the request is denied, you can request an appeal on the member's behalf by completing the Request for Redetermination of Medicare Prescription Drug Denial Form.
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
- All in-patient hospital admissions, including medical, surgical, skilled nursing, and rehabilitation
- All miscellaneous/unlisted or not otherwise specified codes
- All out-of-network services (excluding emergency services)
- All services that may be considered experimental and/or investigational
- Ambulance:
- Certain types of scheduled, nonemergency ambulance trips
- Elective/non-emergent air ambulance transportation
- Cardiac and pulmonary rehabilitation
- Certain outpatient diagnostic tests
- Durable medical equipment (DME):
- All DME rentals and rent-to-purchase items
- Purchase of all items more then $750 in total billed charges
- Purchase of prosthetics and orthotics more than $750 in total billed charges
- Purchase of all wheelchairs (motorized and manual) and all wheelchair accessories (components) regardless of cost per item
- Elective transfers for inpatient and/or outpatient services between acute care facilities
- Home health
- Hyperbaric oxygen
- Inpatient services
- 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.
- Nutritional supplements
- Pain management — external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, and injections/nerve blocks
- Radiology outpatient services (authorized by Evolent):
- CCTA
- CT/CTA
- MRI/MRA
- MUGA scan
- Myocardial perfusion imaging
- PET scan
- Religious non-medical health care institutions (RNHCI)
- Speech therapy, occupational therapy, and physical therapy provided in home or outpatient setting, after the first visit per therapy discipline/type
- Surgery
- Surgical services that may be considered cosmetic, including but not limited to:
- Blepharoplasty
- Gastric bypass/vertical band gastroplasty
- Mastectomy for gynecomastia
- Mastopexy
- Maxillofacial
- Panniculectomy
- Penile prosthesis
- Plastic surgery/cosmetic dermatology
- Reduction mammoplasty
- Septoplasty
- Transplants, including transplant evaluations
H8212_001_126225_M