Prior Authorizations

Effective May 1, 2023, AmeriHealth Caritas North Carolina (ACNC) will require prior authorization via eviCore healthcare for selected health care services. Refer to the March 30, 2023, provider notice (PDF) for more details.

Authorization requests received prior to 5/1/23 and approved for date of service after 5/1/23 will be honored without further action needed from the provider or member.

Use our Prior Authorization Lookup tool for immediate guidance on prior authorizations.

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

ACNC and our benefit management service collaborators will make authorization decisions based on the clinical information provided in the request. See the boxes below for specific submission instructions. Prior authorizations and requirements for the services on this list are subject to change.

Services that require prior authorization

Request prior authorization for diagnostic sleep testing via ACNC’s benefit management service collaborator, eviCore healthcare, at www.evicore.com/provider#login 24 hours a day, 7 days a week. Use the Prior Authorization Lookup tool for immediate guidance. For medically urgent (less than 48 hours) service requests online, please indicate the procedure is NOT routine/standard. 
  • Urgent/routine/standard authorizations: 1-877-506-5193
  • Fax additional clinical information: 1-866-999-3510
  • Client and Provider Services: 1-800-646-0418 (Option 4)
  • eviCore healthcare Clinical Guidelines and forms

Request prior authorization for DME* via ACNC’s benefit management service collaborator, eviCore healthcare, at www.evicore.com/provider#login, 24 hours a day, 7 days a week. 

*Selected DME authorizations may still be performed by ACNC instead of eviCore. Please use the Prior Authorization Lookup tool for the most accurate guidance.

For medically urgent (less than 48 hours) service requests online, please indicate the procedure is NOT routine/standard. 

  • Urgent/routine/standard authorizations: 1-877-506-5193
  • Fax additional clinical information: 1-866-999-3510
  • Client and Provider Services: 1-800-646-0418 (Option 4)
  • eviCore healthcare Clinical Guidelines and forms
Request authorization from ACNC Utilization Management for elective procedures services 24 hours a day, 7 days a week. Use the Prior Authorization Lookup tool for immediate guidance. Prior authorizations are best submitted via ACNC’s provider portal called NaviNet. Submit via the Workflows menu. A PDF form may be found here (Prior Authorization Request Form [PDF])  and submitted by fax.

  • Urgent/routine/standard authorizations: 1-833-900-2262 (8 a.m. to 5 p.m., Monday to Friday)
  • After hours, weekends and holidays, call Member Services at 1-855-375-8811.
  • Fax 1-833-893-2262.
Prior authorization from ACNC is required for the below elective procedures:

  • Cochlear implantation
  • Gastric restrictive procedure/surgeries
  • Hyperbaric oxygen
  • Hysterectomy (hysterectomy consent form required)
  • Surgical services that may be considered cosmetic, including:
    • Blepharoplasty
    • Breast reconstruction not associated with a diagnosis of breast cancer
    • Mastectomy for gynecomastia
    • Mastopexy
    • Maxillofacial
    • Panniculectomy
    • Penile prosthesis
    • Plastic surgery/cosmetic dermatology
    • Reduction mammoplasty
    • Septoplasty
  • 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 would be endangered if they 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 North Carolina Department of Health and Human Services (NCDHHS)  Abortion Statement Form along with 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.
Request prior authorization for genetic testing via ACNC’s benefit management service collaborator, eviCore healthcare, at www.evicore.com/provider#login, 24 hours a day, 7 days a week. Use the Prior Authorization Lookup to for immediate guidance. For medically urgent (less than 48 hours) service requests online, please indicate the procedure is NOT routine/standard. 
  • Urgent/routine/standard authorizations: 1-877-506-5193
  • Fax additional clinical information: 1-844-545-9213
  • Client and Provider Services: 1-800-646-0418 (Option 4)
  • eviCore healthcare Clinical Guidelines and forms

See the Physical Therapy and Occupational Therapy sections for home health authorization requirements for those services.

Request authorization from ACNC Utilization Management for home-based services services 24 hours a day, 7 days a week. Use the Prior Authorization Lookup tool for immediate guidance. To request a prior authorization via ACNC's provider portal called NaviNet, submit via the Workflows menu. A PDF form may be found here (Prior Authorization Request Form [PDF]) and submitted by fax.

  • Urgent/routine/standard authorizations: 1-833-900-2262 (8 a.m. to 5 p.m., Monday to Friday)
  • After hours, weekends and holidays, call Member Services at 1-855-375-8811.
  • Fax 1-833-893-2262.

Prior authorization from ACNC is required for the below home-based services: 

  • Home health aide services
  • Home health speech therapy and skilled nursing (after six combined visits, regardless of modality)
  • Home infusion services and injections 
  • Hospice inpatient services
  • Personal care services
  • Private duty nursing (extended nursing services)

Request authorization from ACNC Utilization Management for inpatient hospital services services 24 hours a day, 7 days a week. Use the Prior Authorization Lookup tool for immediate guidance. To request a prior authorization via ACNC's provider portal called NaviNet, submit via the Workflows menu. A PDF form may be found here (Prior Authorization Request Form [PDF])  and submitted by fax.
  • Urgent/routine/standard authorizations: 1-833-900-2262 (8 a.m. to 5 p.m., Monday to Friday)
  • After hours, weekends and holidays, call Member Services at 1-855-375-8811.
  • Fax 1-833-893-2262.
Prior authorization from ACNC is required for the below inpatient hospital services: 
  • All inpatient hospital admissions, including medical, surgical, skilled nursing, long-term acute care and rehabilitation
  • Behavioral health
  • Elective transfers for inpatient and/or outpatient services between acute care facilities.
  • Gastroenterology services — (codes 91110 and 91111 only)
  • Gender-affirming services
  • Long-term care initial placement (while enrolled with the plan — up to 90 days)
  • Medical detoxification
  • Obstetrical admissions, newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after cesarean section

Request prior authorization via ACNC’s benefit management service collaborator, eviCore healthcare, at www.evicore.com/provider#login, 24 hours a day, 7 days a week. Use the Prior Authorization Lookup tool for immediate guidance. For medically urgent (less than 48 hours) service requests online, please indicate the procedure is NOT routine/standard. 
  • Urgent/routine/standard authorizations: 1-877-506-5193
  • Fax additional clinical information: 1-800-540-2406
  • Client and Provider Services: 1-800-646-0418 (Option 4)
  • eviCore healthcare Clinical Guidelines and forms

Prior authorization is not required; however, providers are asked to notify ACNC Utilization Management regarding all newborn deliveries and with maternity obstetrical services (after first visit) and outpatient care (includes observation). 

  • 1-833-900-2262 (8 a.m. to 5 p.m., Monday to Friday)
  • After hours, weekends and holidays, call Member Services at 1-855-375-8811.
  • Fax 1-833-893-2262.

Occupational therapy requires prior authorization after the initial assessment or a reassessment. This applies to private, outpatient facility-based and home health occupational therapy services.

Request prior authorization via ACNC’s benefit management service collaborator, eviCore healthcare, at www.evicore.com/provider#login, 24 hours a day, 7 days a week. Use the Prior Authorization Lookup tool for immediate guidance. For medically urgent (less than 48 hours) service requests online, please indicate the procedure is NOT routine/standard. 

  • Urgent/routine/standard authorizations: 1-877-506-5193
  • Fax additional clinical information: 1-855-774-1319
  • Client and Provider Services: 1-800-646-0418 (Option 4)
  • eviCore healthcare Clinical Guidelines and forms

Request prior authorization via ACNC’s benefit management service collaborator, eviCore healthcare, at www.evicore.com/provider#login, 24 hours a day, 7 days a week. Use the Prior Authorization Lookup tool for immediate guidance. For medically urgent (less than 48 hours) service requests online, please indicate the procedure is NOT routine/standard. 

  • Urgent/routine/standard authorizations: 1-877-506-5193
  • Fax additional clinical information: 1-800-540-2406
  • Client and Provider Services: 1-800-646-0418 (Option 4)
  • eviCore healthcare Clinical Guidelines and forms

Physical therapy requires prior authorization after the initial assessment or a reassessment. This applies to private, outpatient facility-based services and home health physical therapy services.

Request prior authorization via ACNC’s benefit management service collaborator, eviCore healthcare, at www.evicore.com/provider#login, 24 hours a day, 7 days a week. Use the Prior Authorization Lookup tool for immediate guidance. For medically urgent (less than 48 hours) service requests online, please indicate the procedure is NOT routine/standard. 

  • Urgent/routine/standard authorizations: 1-877-506-5193
  • Fax additional clinical information: 1-855-774-1319
  • Client and Provider Services: 1-800-646-0418 (Option 4)
  • eviCore healthcare Clinical Guidelines and forms

Request prior authorization via ACNC’s benefit management service collaborator, eviCore healthcare, at www.evicore.com/provider#login, 24 hours a day, 7 days a week. Use the Prior Authorization Lookup tool for immediate guidance. For medically urgent (less than 48 hours) service requests online, please indicate the procedure is NOT routine/standard. 

  • Urgent/routine/standard authorizations: 1-877-506-5193
  • Fax additional clinical information: 1-800-540-2406
  • Client and Provider Services: 1-800-646-0418 (Option 4)
  • eviCore healthcare Clinical Guidelines and forms

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

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.

  • Computed tomography angiography (CTA)
  • Computed tomography (CT)
  • Coronary computed tomography angiography (CCTA)
  • Magnetic resonance angiography (MRA)
  • Magnetic resonance imaging (MRI)
  • Multiple-gated acquisition scan (MUGA)
  • Myocardial perfusion imaging (MPI) 
  • Positron emission tomography (PET)

Weekend, holiday and after-hours prior authorization requests*

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

Weekend, holiday and after-hours requests for prior authorization 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 voicemail

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

*NIA's hours are 8:00 a.m. – 8:00 p.m., E. T., Monday through Friday, excluding holidays. Emergency room, observation care and inpatient imaging procedures do not require prior authorization.

Speech therapy requires prior authorization after the initial assessment or a reassessment. This applies to private and outpatient facility-based services. See Home-Based Services for home health care. 

Request authorization from ACNC Utilization Management for speech therapy services 24 hours a day, 7 days a week. Use the Prior Authorization Lookup tool for guidance. To request a prior authorization via ACNC’s provider portal called NaviNet, submit via the Workflows menu. A PDF form may be found here (Prior Authorization Request Form [PDF]) and submitted by fax.

  • Urgent/routine/standard authorizations: 1-833-900-2262 (8 a.m. to 5 p.m., Monday to Friday)
  • After hours, weekends and holidays, call Member Services at 1-855-375-8811.
  • Fax 1-833-893-2262.

Request authorization from ACNC Utilization Management for transplants and transplant evaluations 24 hours a day, 7 days a week. Use the Prior Authorization Lookup tool for guidance. To request a prior authorization via ACNC’s provider portal called NaviNet, submit via the Workflows menu. A PDF form may be found here (Prior Authorization Request Form [PDF]) and submitted by fax.

  • Urgent/routine/standard authorizations: 1-833-900-2262 (8 a.m. to 5 p.m., Monday to Friday)
  • After hours, weekends and holidays, call Member Services at 1-855-375-8811.
  • Fax 1-833-893-2262.

Services that do not require prior authorization

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

  • 30-hour observations (except for Maternity — notification required)
  • Dialysis
  • Emergency room services (in-network and out-of-network)
  • Family planning services (in- or out-of-network)
  • Local health department services
  • Low-level plain films — X-rays, EKGs
  • Post-operative pain management (must have a surgical procedure on the same date of service)
  • Post-stabilization services (in-network and out-of-network)
  • Primary care provider (PCP)
  • School-based clinical services covered by standard plans
  • Screenings/wellness care as part of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services for members under age 21
  • Vision services (routine)
  • Women's health care (OB-GYN Services)

If you do not see the service you are seeking, please call ACNC Utilization Management at 1-833-900-2262.

Providers