Some services and medications need to be approved as "medically necessary" by AmeriHealth Caritas Pennsylvania before your PCP or other health care provider can help you to get these services. This process is called "prior authorization."
Prior authorization process
- Your PCP or other health care provider must give AmeriHealth Caritas Pennsylvania information to show that the service or medication is medically necessary.
- AmeriHealth Caritas Pennsylvania nurses or pharmacists review the information. They use clinical guidelines approved by the Department of Human Services to see if the service or medicine is medically necessary.
- If the request cannot be approved by an AmeriHealth Caritas Pennsylvania nurse or pharmacist, an AmeriHealth Caritas Pennsylvania doctor will review the request.
- If the request is approved, we will let you and your health care provider know it was approved.
- If the request is not approved, a letter will be sent to you and your health care provider telling you the reason for the decision.
- If you disagree with the decision, you may file a complaint or grievance and/or request a fair hearing. See complaints, grievances and fair hearings for more information.
- You may also call Member Services for help in filing a complaint or grievance, or requesting a fair hearing.
Services that need prior authorization
All elective transfers for inpatient and/or outpatient services between acute care facilities.
All elective transplant evaluations and procedures.
Elective/non-emergent air ambulance transportation.
Skilled Nursing Facility admissions for alternate levels of care in a facility, either free-standing or part of a hospital, that accepts patients in need of skilled level rehabilitation and/or medical care that is not necessary to be delivered in a hospital. This does not include Long-Term Care.
Services or durable medical equipment (DME) received from providers or hospitals not in the AmeriHealth Caritas Pennsylvania network (except for tobacco cessation counseling sessions, emergency services, family planning services, and any Medicare-covered services from a Medicare provider if you have Medicare coverage).
Elective (non-emergency) admission to a hospital.
Some medical or surgical procedures performed in a short procedure unit (SPU) or ambulatory surgical unit (ASU), either hospital-based or free-standing, including but not limited to, the following:
- Steroid injections or blocks administered for pain management.
- Obesity surgery.
- Binding or removing veins.
All non-emergency plastic or cosmetic procedures (other than those immediately following traumatic injury) including, but not limited to, the following:
- Plastic surgery for eyelids.
- Breast reduction.
- Plastic surgery of the nose.
Elective termination of pregnancy.
Admission to a nursing or rehabilitation facility.
Therapy services, after the first 24 combined visits, including outpatient physical, occupational, and speech therapy services; aquatic therapy; and cardiac and pulmonary rehabilitation services with an AmeriHealth Caritas Pennsylvania network provider.
Cardiac and pulmonary rehabilitation services.
Home health services, after 18 visits for each service, including skilled nursing visits; home health aide visits; and physical, occupational, and speech therapy. The member must be re-evaluated every 60 days.
All shift care/private duty nursing services (including home health aide).
All DME monthly rentals in excess of $750 per month cost/charge. All wheelchair rentals (motorized and manual) and all wheelchair items.
Exceptional DME purchases:
- Purchase of all items in excess of $750.
- The purchase of all wheelchairs (motorized and manual) and all wheelchair items (components) regardless of cost per item.
- Tube feedings and nutritional supplements (enterals)
- When the member is age 21 or over.
- If the dollar amount is in excess of $500/month for members under age 21 or for certain items that are more than $500/month.
- Diapers and/or pull-up diapers, when medically necessary, when requesting:
- More than 300 generic diapers and/or pull-up diapers per month.
- Brand-specific diapers.
- Diapers supplied by a DME provider.
- Note: Prior authorization is not required when getting diapers drop-shipped through the AmeriHealth Caritas Pennsylvania diaper supplier.
- Any service or product not covered by the Medical Assistance program.
- Some outpatient diagnostic tests and procedures.
- Chiropractic services with an AmeriHealth Caritas Pennsylvania network provider, after the 24th visit if the member is under the age of 18.
- Inpatient or out-of-network hospice services.
- Some specialty dental services.
- Outpatient radiology services (prior authorization by National Imaging Associates Inc.).
- PET and CT scans, MRI, MRA, and nuclear cardiology.
- Prescribed pediatric extended care center and medical day care.
- Ambulance transportation to and from prescribed pediatric extended care center (PPECC) and medical day care per specific guidelines.
- Some formulary prescription drugs, all non-formulary prescription drugs, some over-the-counter non-prescription drugs, and some DME supplies obtained through an AmeriHealth Caritas Pennsylvania network pharmacy (e.g., glucometers).
- All transplant evaluations and consultations.
- Elective/non-emergent air ambulance transportation.
- Genetic laboratory testing.
As an AmeriHealth Caritas Pennsylvania member, you are not responsible to pay for medically necessary, covered services. You may, however, be responsible for a copay.
You may have to pay when one or more of these situations apply:
- A service is provided without prior authorization when prior authorization is required.
A service is provided by a provider who is not in the AmeriHealth Caritas Pennsylvania network and prior authorization was not given to see this provider (except for emergency services, family planning services, and any Medicare-covered services from a Medicare provider if you have Medicare coverage).
- The service provided is not covered by AmeriHealth Caritas Pennsylvania and your provider told you that it was not covered before you received the service. Your health care provider can also bill you for co-pays that were not paid at the time you received the service. See If you get a bill or statement and co-payment schedule (PDF).