Preauthorizations

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).

Preauthorization process

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

Inpatient

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.

Plastic surgery

Surgical services that may be considered cosmetic, including, but not limited to:

Blepharoplasty
Mastectomy for gynecomastia
Mastopexy
Maxillofacial (all codes applicable)
Panniculectomy
Penile prosthesis
Plastic surgery/cosmetic dermatology
Reduction mammoplasty
Septoplasty
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-based services

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

For outpatient pharmacy, contact Gainwell.
For physician-administered medications, contact PerformRx.

Pain management

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.

Members