Some services and medications need to be approved as "medically necessary" by AmeriHealth Caritas Northeast before your PCP or other health care provider can help you get these services. This process is called "prior authorization."
Prior authorization process
- Your PCP or other health care provider must give AmeriHealth Caritas Northeast information to show that the service or medication is medically necessary.
- AmeriHealth Caritas Northeast nurses or pharmacists review the medical information. They use clinical guidelines approved by the Department of Human Services to see if the service or medication is medically necessary.
- If the request cannot be approved by an AmeriHealth Caritas Northeast nurse or pharmacist, an AmeriHealth Caritas Northeast 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
- Services or durable medical equipment (DME) received from providers or hospitals not in the AmeriHealth Caritas Northeast 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).
- 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 Northeast network provider.
- Cardiac and pulmonary rehabilitation services.
- Home health services, after 6 visits for each service, including skilled nursing visits; home health aide visits; and physical, occupational, and speech therapy.
- All DME purchases or monthly rentals that cost more than $750 per item in billed charges, are mandatory review items, and:
- Tube feedings and nutritional supplements (enterals)
- When the member is age 21 or over, or 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, for members ages 3 years and over, 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 Northeast diaper supplier.
- Tube feedings and nutritional supplements (enterals)
- Any service or product not covered by the Medical Assistance program.
- Some outpatient diagnostic tests and procedures.
- Chiropractic services with an AmeriHealth Caritas Northeast network provider, after the first visit.
- 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 extended care center and medical day care.
- 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 Northeast network pharmacy (e.g., glucometers).
- All transplant evaluations and consultations.
- Air ambulance transportation.
As an AmeriHealth Caritas Northeast member, you are not responsible for paying 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 Northeast 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 Northeast 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 copay schedule (PDF).