AmeriHealth Caritas North Carolina will need to approve some treatments and services before you receive them. AmeriHealth Caritas North Carolina may also need to approve some treatments or services for you to continue receiving them. This is called preauthorization.
AmeriHealth Caritas North Carolina will honor your existing preauthorizations (preapprovals) for benefits and services for the first 90 days of your enrollment.
Services requiring preauthorization include, but are not limited to, the services listed below:
- Air ambulance
- Services performed by providers not in the AmeriHealth Caritas North Carolina network (emergency services never require prior authorization even if the provider is out-of-network)
- Services that are not identified with specific codes (miscellaneous) and services that do not identify pricing for provider payment
- Behavioral health
- Psychological and neuropsychological testing
- Electroconvulsive therapy, environmental intervention, interpretation or explanation of results, unlisted psychiatric services
- Mobile crisis intervention for 33+ units
- Ambulatory detox (Level 1-WM)
- Medically monitored detox (Level 3.7 WM)
- Mental health partial hospitalization
- Facility-based crisis services (prior authorization required after first seven days)
- Outpatient opioid treatment
- Substance Abuse Comprehensive Outpatient Treatment/SACOT (Level 2.5) preauthorization required after first 60 days in a state fiscal year
- Medically Supervised Detoxification Crisis Stabilization (ADATC/ASAM Level 3.9 WM) preauthorization required after the first eight hours of admission
- Research based intensive behavioral health treatment
- Chiropractic care
- Cochlear implantation
- Contact lenses (including dispensing fees)
- Gastric bypass/vertical band gastroplasty
- Hyperbaric oxygen
- Hysterectomy (Hysterectomy Consent form required)
- Elective abortions
- Implants (over $750)
- Transplants, including transplant evaluations
- Elective procedures, including, but not limited to: joint replacements, laminectomies, spinal fusions, discectomies, vein stripping, laparoscopic/exploratory surgeries
- Therapy (speech, occupational and physical)
- Speech, occupational and physical therapy require prior authorization after initial assessment or reassessment. This applies to private and outpatient facility based services.
- Plastic surgery
- Surgical services that may be considered cosmetic, including, but not limited to:
- Mastectomy for gynecomastia
- Maxillofacial (all codes applicable)
- Penile prosthesis
- Plastic surgery/cosmetic dermatology
- Reduction mammoplasty
- Breast reconstruction not associated with a diagnosis of breast cancer
- Durable medical equipment (DME) equal to or greater than $750
- DME leases or rentals and custom equipment
- Diapers/pull-ups (age 3 and older) for amounts over the state published quantity limits
- Enteral nutritional supplements
- Prosthetics and custom orthotics
- All unlisted or miscellaneous items, regardless of cost
- Negative pressure wound therapy
- Implantable bone conduction hearing aids (BAHA) — must be Food and Drug Administration (FDA)-approved
- Soft band bone conduction hearing aid
- Replacement of identical replacement sound processor — not covered under warranty
- Replacement for sound processor when request is for an upgraded processor
- Cochlear and auditory brainstem implant external parts replacement and repair
- All speech processors not covered under warranty
- Replacement for speech processor when request is for an upgraded processor
- All inpatient hospital admissions, including medical, surgical, skilled nursing, long-term acute and rehabilitation
- Behavioral health
- Obstetrical admissions, newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after cesarean section
- Medical detoxification
- Elective transfers for inpatient and/or outpatient services between acute care facilities
- Long-term care initial placement (while enrolled with the plan —up to 90 days)
- Home-based services
- Home health care (physical, occupational and speech therapy) and skilled nursing (after six combined visits, regardless of modality)
- Home infusion services and injections (prior authorization required for providers who are not in the AmeriHealth Caritas North Carolina network)
- Home health aide services
- Private duty nursing (extended nursing services)
- Personal care services
- Pain management
- External infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, nerve blocks and epidural steroid injections
- Advanced outpatient imaging services (through NIA)
- Nuclear cardiology
- Computed tomography angiography (CTA)
- Coronary computed tomography angiography (CCTA)
- Computed tomography (CT)
- Magnetic resonance angiography (MRA)
- Magnetic resonance imaging (MRI)
- Myocardial perfusion imaging (MPI)
- Positron emission tomography (PET)
Services requiring notification
AmeriHealth Caritas North Carolina requests that you or your provider let us know when you receive any of the following services so that we can help you get any additional care that you may need.
- Newborn deliveries
- Maternity obstetrical services (after first visit) and outpatient care (includes observation)
- Behavioral health — crisis intervention: notification required (within two business days) post-service (mobile crisis for up to 32 units, facility based crisis for children/ adolescents and facility based crisis services for the first seven days)
- Intensive outpatient services for substance use disorders (SACOT/ASAM Level 2.5) for the first 60 days in a state fiscal year
- Continuation of covered services for a new member transitioning to the plan the first 90 calendar days of enrollment
Services that do not require authorization or notification
The following services do not require preauthorization or notification:
- Emergency department services (in-network and out-of-network)
- 48-hour observations (except for maternity — notification required)
- Low-level plain films — X-rays and electrocardiograms (EKGs)
- Family planning services
- Post-stabilization services (in-network and out-of-network)
- Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services
- Women's health care by in-network providers (OB/GYN services)
- Routine vision services
- Post-operative pain management (must have a surgical procedure on the same date of service)
- Behavioral health and substance use disorder outpatient therapy
- Behavioral health medicine management
- High intensity withdraw management at an Alcohol and Drug Abuse Treatment Center (ADATC) (ASAM Level 3.9) WM for the first eight hours
What happens after we get your service authorization request?
Your plan uses a group of qualified health care professionals for reviews. Their job is to be sure that the treatment or service you asked for is covered by your plan and that it will help with your medical condition. Your plan’s nurses, doctors and behavioral health clinicians will review your provider’s request.
The plan team uses policies and guidelines approved by the North Carolina Department of Health and Human Services to see if the service is medically necessary.
Sometimes your plan may deny or limit a request your provider makes. This decision is called an adverse benefit determination. When this happens, you can request any records, standards and policies the team used to decide on your 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 giving the reason for the decision.
If you receive a denial and you do not agree with our decision, you may ask your plan for an "appeal." You can call your plan, make your request online or send in the appeal form you will find with your decision notice.
Prior authorization requests for children under age 21
Special rules apply to decisions to approve medical services for children under age 21. The plan cannot say no to a request for children under 21 years old just because of plan policies, policy limits or rules. They must complete another review to help them approve needed care. They will use federal EPSDT rules. These rules help the plan team to take a careful look at:
- The child's health problem, and;
- The service or treatment your provider asked for.
Your plan must approve services that are not included in plan policies when the plan’s review team finds that a child needs them to get well or to stay healthy. This means that the plan’s review team must agree with your provider that the service will:
- Correct or improve a health problem; or
- Keep the health problem from getting worse; or
- Prevent the development of additional health problems.
Important details about services coverable by the federal EPSDT guarantee:
- Your provider must ask your plan for the service.
- Your provider must ask your plan to approve services that are not covered by your plan.
- Your provider must explain clearly why the service is needed to help treat a child’s health problem. Your plan’s EPSDT reviewer must agree. Your plan will work with your provider to get any information the plan team needs to make a decision. The plan will apply EPSDT rules to the member’s health condition. Your provider must tell your plan how a service will help a child to improve a health problem or to keep it from getting worse.
The plan must approve these services with an "EPSDT review" before your provider gives them.
Learn more about the Medicaid health plan for children (EPSDT), and visit the state of North Carolina website for the EPSDT guarantee.
Preauthorization and time frames
We will review your request for a preauthorization within the following time frames:
Standard review: A decision will be made within 14 days after we receive your request.
- Expedited (fast track) review: A decision will be made and you will hear from us within three days of your request.
In most cases, you will be given at least 10 days' notice if any change (to reduce, stop or restrict services) is being made to current services. If we approve a service and you have started to receive that service, we will not reduce, stop or restrict the service during the approval period unless we determine the approval was based on information that was known to be false or wrong.
If we deny payment for a service, we will send a notice to you and your provider the day the payment is denied. These notices are not bills. You will not have to pay for any care you received that was covered by your plan or by Medicaid, even if your plan later denies payment to the provider.
You may have to pay for a service we do not cover. Your provider will ask you to sign an agreement to pay for the non-covered service before you receive it.