Prior Authorizations

Prior authorization lookup tool

AmeriHealth Caritas North Carolina providers may need to complete a prior authorization request form (PDF) before administering some health services to members.

Prior Authorizations are subject to change.

A member does not need authorization to see a primary care physician or a local health department. AmeriHealth Caritas North Carolina does not require referrals for any services.

Prior Authorization Lookup Tool

Use our Prior Authorization Lookup Tool to find out if a service requires prior authorization.

Submit a prior authorization request for physical health services

By phone

Call our Utilization Management department at 1-833-900-2262 from 8 a.m. to 5 p.m., Monday to Friday.

For prior authorizations after hours, weekends and holidays, call Member Services at 1-855-375-8811.

By fax

Fax to 1-833-893-2262

Online

Providers can also use Jiva for online prior authorization via our secure provider portal by signing on to NaviNet and accessing the Jiva portal.

This list is subject to change. If you do not see the service you are seeking, please call Utilization Management at 1-833-900-2262 for the most up-to-date prior authorization information.

  • All out of network services excluding emergency services.
  • All services that may be considered Experimental and/or Investigational
  • All miscellaneous/unlisted or not otherwise specified codes
  • All services not listed on the North Carolina Department of Health and Human Services (DHHS) Fee Schedule
  • Out of Network Specialty Visits
  • Elective Air Ambulance

Inpatient

  • 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 ).
  • Gastroenterology services - (codes 91110 and 91111 only)
  • Gender reassignment services
  • Genetic Testing

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 (see pharmacy list of HCPCS codes that require prior authorization)
  • Home Health Aide Services.
  • Private duty nursing (extended nursing services),
  • Personal Care Services•
  • Enteral Feedings
  • Hospice Inpatient Services
  • Termination of Pregnancy
    • First and second trimester terminations of pregnancy require prior authorization and are covered in the following two circumstances:
      • The member's life is endangered if she were to carry the pregnancy to term;
      • The pregnancy is the result of an act of rape or incest.
    • Submit the physician's certification on the Abortion Justification Form and the complete medical record.  The form must be completed in accordance with the instructions and must accompany the claims for reimbursement. All claims and certification forms will be retained by the Plan.

Therapy (speech, occupational, and physical)

Speech, occupational, and physical therapy require prior authorization after initial assessment or re-assessment. This applies to private and outpatient facility based services.

Transplants, including transplant evaluations

Durable medical equipment (DME)

  • Items with billed charges 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 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 Auditor y 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
  • Hyperbaric Oxygen
  • Gastric Restrictive Procedure/Surgeries
  • Hysterectomy (Hysterectomy Consent form required)

Elective procedures including but not limited to: joint replacements, laminectomies, spinal fusions, discectomies, vein stripping, laparoscopic /exploratory surgeries

  • Surgical services that may be considered cosmetic, including
    • Blepharoplasty
    • Mastectomy for Gynecomastia
    • Mastopexy
    • Maxillofacial
    • Panniculectomy
    • Penile Prosthesis
    • Plastic Surgery/Cosmetic Dermatology
    • Reduction Mammoplasty
    • Septoplasty
  • Breast reconstruction not associated with a diagnosis of breast cancer
  • Hysterectomy (hysterectomy consent form required)
  • Cochlear implantation
  • Pain management including but not limited to:
    • External infusion pumps
    • Spinal cord neurostimulators
    • Implantable infusion pumps
    • Radiofrequency ablation
    • Nerve blocks
    • Epidural steroid injections
  • The following Radiology Services, when performed as an outpatient service, require prior authorization by AmeriHealth Caritas North Carolina's radiology benefits vendor, National Imaging Associates Inc. (NIA).
    • 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).
    • Multiple-gated acquisition scan (MUGA)

To request prior authorization contact AmeriHealth Caritas North Carolina's radiology benefits vendor (NIA) via their provider web-portal at radmd.com or by calling 1-800-424-4953 Monday through Friday 8:00 a.m. – 8:00 p.m. (EST).

The ordering physician is responsible for obtaining a Prior Authorization number for the requested radiology service. Patient symptoms, past clinical history and prior treatment information will be requested by NIA and the ordering physician should have this information available at the time of the call.

Requests can be submitted online – The NIA web site is available 24 hours a day to providers.

Weekend, holiday and after-hours requests for preauthorization of outpatient elective imaging studies may be called in to NIA and a message may be left at 1-800-424-4784 which will be retrieved the following business day.

Requests left on voice mail:

NIA will contact the requesting Provider's office within one business day of retrieval of the voice mail request to obtain necessary demographic and clinical information to process the request.

*NIA's hours are 8:00 a.m. – 8:00 p.m. Eastern Time, Monday through Friday, excluding holidays. Emergency room, Observation Care and inpatient imaging procedures do not require Prior Authorization.

The following services will not require prior authorization from AmeriHealth Caritas North Carolina:

  • Emergency Room Services (in-network and out-of-network)
  • 48-Hour Observations (except for Maternity – notification required)
  • Low-level plain films - X-rays, EKG's
  • Family Planning Services (in or out of network)
  • Post Stabilization Services (in-network and out-of-network)
  • EPDST Screening Services
  • Women's Healthcare (OB-GYN Services)
  • Routine Vision Services
  • Dialysis
  • Post-operative pain management (must have a surgical procedure on the same date of service).
  • Services rendered at school-based clinics
  • Primary care provider (PCP)
  • Local health department

Providers will be asked to notify AmeriHealth Caritas North Carolina when the following services are delivered:

  • All newborn deliveries
  • Maternity obstetrical services (after first visit) and outpatient care (includes observation).