Prior Authorizations

Some services or items need approval from AmeriHealth Caritas Ohio before you can get the service. This is called Prior Authorization. For services that need prior authorization, AmeriHealth Caritas Ohio decides whether a requested service is medically necessary before you get the service.

Your provider must make a request to AmeriHealth Caritas Ohio through the Ohio Department of Medicaid portal for approval before you get the service. Services requiring prior authorization include, but are not limited to, those listed below. 

If you need help understanding when a service, item, or medicine is medically necessary or would like more information, please call Member Services at 1-833-764-7700 (TTY 1-833-889-6446).

Physical health services requiring prior authorization

  • 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 under 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 Gainwell (pharmacy), PerformRx (inpatient)
  • Transplants (prior authorization for transplants must be requested directly from the appropriate consortium:

Ohio Solid Organ Transplantation Consortium

9200 Memorial Dr.
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

  • 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 health care (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

Physical health services that require notification

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

Behavioral health services requiring prior authorization

  • Adult (21 and over) Inpatient Hospitalizations (mental health and/or substance use disorder)
  • Psychological and neuropsychological testing
  • Electroconvulsive therapy
  • Therapeutic Group Services (Day Treatment Per Diem)
  • Assertive Community Treatment
  • Applied Behavioral Analysis Therapy for Autism Spectrum Disorder
  • Substance Use Disorder Partial Hospitalization Program (ASAM 2.5)
  • Substance Use Disorder Residential Treatment (ASAM 3.1, 3.5, 3.7)
  • First and second admissions in a calendar year requires a notification and are not subject to a medical necessity review
  • 31 or more days during either admission requires a prior authorization and medical necessity review
  • Third and subsequent admissions in a calendar year require a prior authorization and medical necessity review
  • Unlisted Psychiatric Services

Services covered by OhioRISE ONLY

  • Child and Adolescent Inpatient Hospitalization (mental health and/or substance use disorder)
  • Intensive Home Based Treatment (IHBT)
  • Intensive and Moderate Care Coordination
  • Psychiatric Residential Treatment Facility 
  • OhioRISE 1915(b) and 1915(c) services

Services requiring notification

  • Substance Use Disorder Residential Treatment (ASAM 3.1, 3.5, 3.7)
  • First and second admissions in a calendar year requires a notification and are not subject to a medical necessity review
  • 31 or more days during either admission requires a prior authorization and medical necessity review
  • Third and subsequent admissions in a calendar year require a prior authorization and medical necessity review

Behavioral health services that do not require authorization

  • Psychotherapy for Mental Health and Substance Use Disorder: Individual, Family, Multiple-family, Group
  • Psychotherapy for Crisis for Mental Health and Substance Use Disorder
  • Behavioral Health Counseling
  • Psychosocial Rehabilitation Services
  • Community Psychiatric Supportive Treatment (Individual and Group)
  • Therapeutic Group Services (Day Treatment Per Hour less than 2.5 hours)
  • Substance Use Disorder Assessment
  • Substance Use Disorder Individual and Group Counseling
  • Substance Use Disorder Case Management
  • Substance Use Disorder Urine Drug Screen Withdrawal Management ASAM 2-WM
  • Clinically Managed Residential Withdrawal Management ASAM 3.2-WM
  • Medically Monitored Inpatient Withdrawal Management ASAM 3.7-WM
  • Substance Use Disorder Intensive Outpatient Program (ASAM 2.1)
  • Substance Use Disorder Peer Support Services (up to 4 hours per day)
  • Evaluation and Management Visits for Mental Health and Substance Use Disorder including home and prolonged visits
  • Psychiatric Diagnostic Evaluation 
  • Smoking and Tobacco Cessation Counseling
  • Screening, Brief Intervention and Referral to Treatment (SBIRT)
  • A Child and Adolescent Needs and Strengths (CANS) assessment
  • Up to 72 hours of Mobile Response Stabilization Services (MRSS), except in accordance with OAC rule 5160-27-13.
  • Depression Screening and Cognitive Behavioral Health Therapies provided in coordination with the Help me Grow program including services performed in the home. The AmeriHealth Caritas Ohio Population Health team will assist with arranging for depression screening and cognitive behavioral health therapies for Members enrolled in the program who are either pregnant or the birth mother of an infant or toddler under three years of age
Members