Prior Authorizations

AmeriHealth Caritas Ohio providers are responsible for obtaining prior authorization for certain services. Your claim may be denied or rejected if the prior authorization is not obtained before the service was rendered.

Prior authorization is not a guarantee of payment for the service authorized. AmeriHealth Caritas Ohio reserves the right to adjust any payment made following a review of the medical record and determination of the medical necessity of the services provided.

A 30-calendar day advance notice of any changes to the list of services requiring prior authorization will be posted under provider alerts and sent to all network providers.

How to obtain prior authorization

Prior Authorization Submission

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

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

AmeriHealth Caritas Ohio standard prior authorization submission procedures

  1. Applies to all services and providers.
  2. Prior authorizations with AmeriHealth Caritas Ohio are required for certain services for participating providers. Please refer to the list of services that require prior authorization in the Provider Manual. For out of network providers, prior authorization is required for all services except emergency services.
  3. AmeriHealth Caritas Ohio has a Prior Authorization call center available for prior authorization requests and education. Our Prior Authorization call center is open Monday – Friday, 8:30 a.m. to 5 p.m. ET. Please call 1-833-735-7700 to reach our Utilization Management department.
  4. After hours and on weekends and holidays, please call the AmeriHealth Caritas Ohio Member Services department at 1-833-764-7700 to be connected with the on-call prior authorization nurse or licensed clinician. Our staff will be able to answer questions and help assist you with your prior authorization request, including requests for inpatient hospitalizations.
  5. For members new to AmeriHealth Caritas Ohio, we will cover a member’s medical or behavioral health condition that is currently being treated or where a prior authorization has been issued, for 90 calendar days following enrollment or until completion of a medical necessity review, whichever comes first. If the member is pregnant and in her second or third trimester, prenatal services will be covered through her pregnancy and up to 60 calendar days after delivery.
  6. For members new to the Plan, AmeriHealth Caritas Ohio will receive a list of existing prior authorizations for its members, and will have a record of those on file.
  7. AmeriHealth Caritas Ohio will pay claims according to the prompt pay requirements for both in-network and out-of-network providers.
  8. AmeriHealth Caritas Ohio may conduct retrospective reviews of claims for services that did not receive prior authorization to ensure medical necessity.
  9. AmeriHealth Caritas Ohio may recover payments from providers for reimbursed services determined not to be medically necessary.
  10. AmeriHealth Caritas Ohio offers information on its prior authorization policies to reduce the risk of recovery for claims paid when the service is determined to not be medically necessary. Prior Authorization requirements are listed in detail in the Provider Manual, in the new provider orientation program, and are available in a searchable tool.
  11. Determination of lack of medical necessity is considered an adverse action and may be appealed through the provider appeals process.
  12. AmeriHealth Caritas Ohio will provide comprehensive, ongoing provider training and outreach to contracted providers. Training will include prior authorization and billing processes to help providers treating our members to avoid delays in payment or member service delivery.
  13. AmeriHealth Caritas Ohio offers additional training materials on its website and these materials are accessible for both in-network and out-of-network providers.

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’s
  • Family planning services (in or out of network)
  • Post stabilization services (in-network and out-of-network
  • EPSDT 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

Services that require notification

Providers will be asked to notify AmeriHealth Caritas Ohio within one business day of when the following services are delivered:

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

For certain behavioral health services, notification is required:

  • Crisis Intervention: Notification required within 2 business days post service.

Providers can notify us by submitting notification via ODM'S PNM provider portal.