AmeriHealth Caritas Ohio will need to approve some treatments and services before you receive them. AmeriHealth Caritas Ohio may also need to approve some treatments or services for you to continue receiving them. This is called preauthorization. You can ask for this.
AmeriHealth Caritas Ohio will honor your existing preauthorizations (preapprovals) for benefits and services for the first 90 days of your enrollment. If you have questions about preauthorizations, please call Member Services at 1-833-764-7700 (TTY 1-833-889-6446).
To request preauthorization, you or your provider can contact AmeriHealth Caritas Ohio by calling Member Services at 1-833-764-7700 (TTY 1-833-889-6446).
To get approval for these treatments or services, the following steps need to occur:
- AmeriHealth Caritas Ohio will work with your provider to collect information to help show us that the service is medically necessary.
- AmeriHealth Caritas Ohio nurses, doctors, and behavioral health clinicians review the information. They use policies and guidelines approved by the Ohio Department of Health and Human Services to see if the service is medically necessary.
- 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 would like to appeal it, talk to your provider. Your provider will work with AmeriHealth Caritas Ohio to determine if there were any problems with the information that was submitted.
Services requiring preauthorization include, but are not limited to, the services listed below:
- 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 AmeriHealth Caritas Ohio Fee Schedule
- Behavioral health
- Inpatient hospitalization
- Psychological and neuropsychological testing
- Electroconvulsive therapy
- Applied behavior analysis (ABA)
- Therapeutic behavioral services
- Community psychiatric supportive treatment
- Psychosocial rehabilitation
- SUD services for ASAM levels of care:
- SUD intensive outpatient program
- SUD partial hospitalization program
- Withdrawal management
- Residential treatment
- Mental health intensive outpatient program
- Mental health partial hospitalization
- Assertive community treatment
- Unlisted psychiatric services,
- Out-of-network specialty visits
- Elective air ambulance
- All inpatient hospital admissions, including medical, surgical, skilled nursing, long-term acute and rehabilitation
- Behavioral health including institution for mental disease
- 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)
- Hospice Inpatient Services
- Chiropractic care for members under 18 years of age
- Cochlear implantation
- Contact lenses (including dispensing fees)
- Enteral feedings
- Gastric bypass/vertical band gastroplasty
- Gastroenterology services – (codes 91110 and 91111 only)
- Gender transition reassignment services
- Genetic testing
- Hyperbaric oxygen
- Hysterectomy (Hysterectomy Consent Form required)
- Elective abortions.
- Implants (over $750).
- 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 she were to carry the pregnancy to term.
- The pregnancy is the result of an act of rape or incest.
- Transplants, excluding transplant evaluations. (See attachment B of this policy for transplant-related requirements)
- 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. This applies to private and outpatient facility-based services.
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)
- 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 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
- Home health care (physical, occupational, and speech therapy) and skilled nursing (authorization is required after 18th visit, 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
Pharmacy and medications
- Contact Gainwell.
- External infusion pumps
- Spinal cord neurostimulators
- Implantable infusion pumps
- Radiofrequency ablation
- Nerve blocks
- Epidural steroid injections
Advanced outpatient imaging services (through National Imaging Associates [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
- All 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
- Continuation of covered services for a new member transitioning to the plan the first 90 calendar days of enrollment
You have direct access to these services, which do NOT require prior authorization or a specialist referral:
- Emergency room services (in network and out of network)
- 48-hour observations (except for maternity — notification required)
- Low-level plain films — X-rays, electrocardiograms (EKGs)
- Children’s screening services
- Primary care services
- School-based clinic services
- 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), including obstetrical ultrasound and routine and preventive health care services
- Home health assessments by a Medicare-certified home health agency
- 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 medication management
- A Child and Adolescent Needs and Strengths (CANS) assessment
- Mobile response stabilization services (MRSS)
- Depression screening and cognitive behavioral health therapies provided in coordination with the Help Me Grow program, including services performed in the home
This is not a complete list, just some examples. Call Member Services at 1-833-764-7700 (TTY 1-833-889-6446) for more information.