Specialists, Prior Authorizations, and Referrals
A specialist is a doctor who has extra training and is an expert on certain health conditions or parts of the body. Your primary care provider (PCP) will know when you need to see a specialist and advise you on what type of specialist you need.
If you have chronic back pain, your PCP might send you to an orthopedist. For heart issues, you might see a cardiologist.
Although referrals are not required, we recommend you contact your PCP before a potential specialist visit to make sure your PCP can better support care coordination for you and your family. Look up your PCP information before your next specialist visit.
Services that require prior authorization
The following is a list of services requiring prior authorization review for medical necessity and place of service. Please note this information may be subject to change.
- Hospital inpatient services (except for maternity and emergency admissions)
- Inpatient mental illness and alcohol and/or substance abuse services
- Organ and tissue transplants
- Inpatient hospice care services
- Home health services
- Skilled nursing facility services
- Outpatient services at hospital or ambulatory facility
- Medical devices and supplies
- Beds — specialty beds such as heavy duty, pediatric, extra wide, and specialty mattresses
- Prosthetic devices
- Microprocessor limbs
- Cochlear implants
- Speech generating devices
- Respiratory devices
- Oral airway devices
- Apnea monitor
- Mobility devices, wheelchairs (power and/or custom), and power operated vehicles
- Phototherapy devices
- Specialty medical devices and equipment
- Defibrillators
- Wound therapy electrical pumps
- Hair prosthesis
- Repairs of durable medical equipment
Prior authorization process, requirements, and restrictions:
Coordination between AmeriHealth Caritas District of Columbia (DC) and your healthcare team is a multi-step process which may require up to 14 days or longer to assure that you are approved for the most appropriate care related to your health condition. The steps listed below are the standard requirements to determine necessary services.
Prior authorization standards and restrictions are determined based upon precise federal and DC laws, rules, regulations, and contractual requirements along with evidence-based medical guidelines and clinical criteria practiced across the country. These rules and guidelines are designed to ensure you receive the right care at the right time. AmeriHealth Caritas DC is committed to working together with you and your healthcare team (your doctors, dentists, nurses, and other providers of care) to help you get healthy, stay healthy, and achieve the best possible outcomes.
- Your PCP or other health care provider must give AmeriHealth Caritas DC information to show that the service or medication is medically necessary.
- AmeriHealth Caritas DC 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 DC nurse or pharmacist, an AmeriHealth Caritas DC 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.
- You may also call Enrollee Services for help in filing a complaint or grievance, or requesting a fair hearing.
Please call 1-844-214-2470 (TTY 711) if you need additional information related to a prior authorization request or appeal.