Prior Authorization

Online

For online prior authorization, providers can use the Medical Authorizations feature inside our secure provider portal (NaviNet) by going to https://www.navinet.net.

In addition to submitting new requests and inquiring about existing authorizations, you will also be able to:

• Verify if no authorization is required.
• Receive auto approvals, in some circumstances.
• Submit amended authorization.
• Attach supplemental documentation.
• Sign up for in-app status change notifications directly from the health plan.
• Access a multi-payer authorization log.
• Submit inpatient concurrent reviews online if you have Health Information Exchange (HIE) capabilities (fax is no longer required).
• Review inpatient admission notifications and provide supporting clinical documentation.

By fax

Medical authorization and other forms are available.

• Fax the medical prior authorization form (PDF) to 1-877-759-6216.
• Fax the behavioral health prior authorization request form (PDF) to 1-855-410-6638.

By phone

• Call our Utilization Management department at 1-888-605-4807 or 1-800-408-7510. Our clinical staff and medical directors are available from 8 a.m. to 5:30 p.m., Monday to Friday, except for company-observed holidays.
• A toll-free fax line is available to receive inbound communication 24 hours a day, seven days a week. Communications received after normal business hours are returned on the next business day, and communications received after midnight from Monday to Friday are responded to on the same business day.
• To contact the Behavioral Health Utilization Management team directly, please call 1-877-464-2911.
• The review of prior authorization requests for radiology services has been delegated to Evolent (formerly National Imaging Associates, Inc.); those requests must be directed to 1-877-517-9177 or https://www1.radmd.com. View the utilization review matrix (PDF) here.

Organ transplant initial evaluation notification

Use the following information to help with the submission of notification for organ transplant evaluations:

• Providers will submit the transplant evaluation notification via the NaviNet provider portal using the Medical Authorizations link, located under Workflows for AmeriHealth Caritas DC.
• Under Service Type, choose Outpatient Transplant Evaluation from the dropdown.
• Medical necessity review will not be required for the initial evaluation.
• Medical necessity review will be required prior to the transplant procedure.
• For organ transplants, contact the Utilization Management transplant team at 1-833-983-7229 from 8 a.m. to 5 p.m., Monday to Friday. Note: Messages will be monitored seven days a week.

After hours, weekends, and holidays

After business hours, on weekends, and on holidays, health care providers, practitioners, and enrollees may contact the Utilization Management department through Enrollee Services at 1-844-214-2470 (TTY 711).

• 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

• Emergency services and Emergency room services, in network and out of network
• Imaging procedures related to emergency room services, observation care, and inpatient care
• Post-stabilization services, in network and out of network
• 48-hour observations, except for maternity, which requires notification
• Low-level plain films, such as X-rays and electrocardiograms (EKGs)
• Family planning services
• In-network obstetric and gynecological (OB/GYN) services
• OB/GYN services for one annual visit and any medically necessary follow-up care for detected conditions. The enrollee must use an AmeriHealth Caritas DC provider for these services.
• Women’s health specialist services (to provide women’s routine and preventive health care services)
• Diagnosis and treatment of sexually transmitted diseases and other communicable diseases, such as tuberculosis and HIV/AIDS, as determined by county health departments
• Podiatry and some dermatology services. The enrollee must use an AmeriHealth Caritas DC provider for these services.
• Immunizations by county health departments and participating primary care providers
• Outpatient therapy — individual, family, or group — after the initial 10 sessions
• Behavioral health counseling and therapy.

• Sterilization reversals
• Cosmetic surgery
• Experimental or investigational services, surgeries, treatments, and medications
• Services that are part of a clinical trial protocol
• Abortion, unless medically necessary to save the life of the mother or prevent long-lasting physical health damage if the pregnancy is carried to term, or in cases of rape or incest.
• Services that are not medically necessary and/or that are not described as a covered service in the Provider Manual