Physical Health Prior Authorizations

AmeriHealth Caritas Ohio does not require referrals to in-network specialists. Prior authorization is required for out-of-network providers.

Prior authorization submission

Per guidance from Ohio Department of Medicaid, AmeriHealth Caritas Ohio providers are expected to submit prior authorization requests and associated attachments through the Ohio Department of Medicaid Provider Network Management (PNM) system.

Additional information regarding this process will be available closer to December 1, 2022.

Physical health services requiring prior authorization

Services requiring prior authorization include, but are not limited to, the list below.

Please note benefit categories that are still pending: Ambulance BH/SUD, Opth/Vision, Non-Par Providers.

  • Elective air ambulance
  • All out-of-network services, excluding emergency services
  • All services that may be considered experimental and/or investigational
  • All services not listed on the Ohio Department of Medicaid Fee Schedule
  • All unlisted miscellaneous and manually priced codes (including, but not limited to, codes ending in “99”)
  • All inpatient hospital admissions, including medical, surgical, skilled nursing, long-term acute, and rehabilitation services
  • Obstetrical admissions, newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after cesarean section
  • Elective transfers for inpatient and/or outpatient services between acute care facilities
  • Medical detoxification
  • Long-term care initial placement (while enrolled with the plan ― up to 90 days)
  • Chiropractic care (prior authorization required for members younger than age 18)
  • Cochlear implantation
  • Durable medical equipment (DME) rentals, leases, and custom equipment
  • Durable medical equipment (DME), prosthetics, and orthotics with billed charges over $750
  • Diapers/pull-ups (ages 4 – 20) for amounts over 300 units
  • Negative pressure wound therapy
  • Elective procedures, including, but not limited to: joint replacements, laminectomies, spinal fusions, discectomies, vein stripping, laparoscopic/exploratory surgeries
  • Gastric restrictive procedure and surgeries
  • Elective termination of pregnancy
  • Speech, occupational, and physical therapy require prior authorization after the 30th visit. This applies to private and outpatient facility based services.
  • Surgical services that may be considered cosmetic, including:
    • Blepharoplasty
    • Mastectomy for gynecomastia
    • Mastopexy
    • Panniculectomy
    • Penile prosthesis
    • Plastic surgery or cosmetic dermatology
    • Reduction mammoplasty
    • Septoplasty
  • Gender reassignment services
  • Genetic testing
  • Hyperbaric oxygen
  • Home-based services:
    • Home health care (physical, occupational, and speech therapy) and skilled nursing (after 18 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)
    • Hospice inpatient services
  • Hysterectomy (Hysterectomy Consent Form required)
  • Cardiac and pulmonary rehabilitation
  • Pain management ― external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, and nerve blocks
  • Pharmacy and medications ― contact PerformRxSM
  • Transplants (prior authorization for transplants must be requested directly from the appropriate consortium:
    • Ohio Solid Organ Transplantation Consortium
      9200 Memorial Drive
      Plain City, OH 43064

      Telephone: 1-614-504-5705
      Fax: 1-614-504-5707
    • Ohio Hematopoietic Stem Cell Transplant Consortium
      9500 Euclid Avenue, Desk R32
      Cleveland, OH 44195

      Telephone: 1-440-585-0759

Fax: 1-440-943-6877

  • The following radiology services, when performed as an outpatient service, require prior authorization by AmeriHealth Caritas Ohio’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)

Physical health services that do not require prior authorization

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

  • Emergency room services (in-network and out-of-network)
  • 48-hour observations (except for maternity ― notification required)
  • Low-level plain films ― X-rays, EKGs
  • Family planning services (in-network or out-of-network)
  • Post-stabilization services (in-network or out-of-network
  • EPSDT screening services
  • Women’s health care (OB/GYN services)
  • Routine vision services
  • Dialysis
  • Postoperative 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

Physical health services that require notification

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

Radiology

Per guidance from Ohio Department of Medicaid, AmeriHealth Caritas Ohio providers are expected to submit prior authorization requests and associated attachments through the Ohio Department of Medicaid Provider Network Management (PNM) system.

Additional information regarding this process will be available closer to the fourth quarter of 2022.

Emergency room, observation care, and inpatient imaging procedures do not require prior authorization.