Prior Authorization Reporting

Prior authorization

Some medical services and treatments need to be approved by your health plan as "medically necessary" before you can get them. Your primary care provider (PCP) or other health care provider must get approval from your health plan — this is called “prior authorization.” This process helps make sure you get the care you need and helps stop fraud, waste, and abuse.

Prior authorization is a process AmeriHealth Caritas District of Columbia uses to make sure certain services, treatments, or medications are medically necessary and right for you.

When your provider requests a service requiring prior authorization, our clinical team reviews the request using medical guidelines and research-based standards. This helps ensure the care is safe, effective, and appropriate for your specific health needs.

This review also helps protect you from unnecessary tests or procedures. All medical services carry some level of risk. For example, surgery can lead to complications, and some imaging tests may expose you to radiation. Studies show that some services may not always be needed. Research estimates that up to 20% – 30% of imaging tests and 15% – 30% of surgical procedures may be unnecessary.

Prior authorization helps make sure you receive the right care at the right time, based on established medical guidelines. Our goal is to support your health and safety by ensuring you receive high-quality care tailored to your diagnosis and individual circumstances.

If a covered service is not approved, you and your provider will be notified, and you will have the right to appeal the decision.

Centers for Medicare & Medicaid Services (CMS) requirement

Every year, AmeriHealth Caritas District of Columbia must post on our website the number of prior authorizations submitted and the number approved or denied. The report must be posted by March 31. This reporting is part of the CMS Interoperability and Prior Authorization Final Rule CMS-0057-F.