Prior authorization requirements
The most up-to-date listing of services requiring prior authorization is listed below.
Prior authorization and referral updates
- PCP to in-network specialists - No referral is required.
Medication requiring prior authorization
- Drugs requiring prior authorization or having any other restrictions are identified in the AmeriHealth Caritas Louisiana printable formulary (PDF) and through the searchable formulary.
Services requiring prior authorization
- Codes requiring authorization (PDF)
- Behavioral codes requiring authorization (PDF)
- Radiology codes requiring authorization (PDF)
The following is a list of services requiring prior authorization review for medical necessity and place of service.
- All out-of-network services
- Air ambulance
- In-patient services
- All in-patient hospital admissions, including medical, surgical and rehabilitation
- Obstetrical admissions/newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after caesarean section
- In-patient medical detoxification
- Elective transfers for inpatient and/or outpatient services between acute care facilities
- Long-term care initial placement if still enrolled with the plan
- Home-based services
- Home health care (PT, OT, ST) and skilled nursing visits (after six combined visits, regardless of modality)
- Private duty nursing — extended nursing services (covered when medically necessary for under age 21)
- Personal care services (covered when medically necessary for under age 21)
- Home health extended services
- Home infusions and injections $250 and over
- Enteral feedings, including related DME
- Hospice services
- Therapy and related services
- Speech therapy, occupational therapy, physical therapy, private/professional speech therapy, and occupational therapy require prior authorization at first visit
- Outpatient facility-based speech and occupational therapy – after 12 visits
- Private/professional and outpatient facility physical therapy – after 12 visits
- Chiropractic care
- Cardiac rehabilitation
- Transplants, including transplant evaluations
- All DME rentals
- DME equipment for billed charges $750 and over:
- Diapers/pull-ups (ages 4 through 20) who qualify:
- Quantities over 200 per month for either or both
- Brand-specific diapers
- Diapers/pull-ups (ages 4 through 20) who qualify:
- Hyperbaric Oxygen
- Implants (over $750)
- Medications: All infusion/injectable medications with billed amounts of $250 or greater.
- Cochlear implantation
- Gastric bypass/vertical band gastroplasty
- Surgical services that may be considered cosmetic, including
- Mastectomy for gynecomastia
- Penile prosthesis
- Plastic surgery/cosmetic dermatology
- Reduction mammoplasty
- Pain management – external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation ,and nerve blocks.
- Radiology services*: NIA frequently asked questions (PDF)
- CT scan
- Nuclear cardiac imaging
- All unlisted and miscellaneous codes
*Prior authorization for CT scans, MRIs/MRAs, and nuclear cardiology services are required for outpatient services only. The ordering physician is responsible for obtaining a prior authorization number for the study requested. Patient symptoms, past clinical history, and prior treatment information will be requested and should be available at the time of the call. (Outpatient studies ordered after normal business hours or on weekends should be conducted by the ordering facility, as requested by the ordering physician. However, the ordering physician must contact UM within 48 hours or the next business day to obtain proper authorization for the studies that will be subject to medical necessity review.) Emergency room, observation care and inpatient imaging procedures do not require prior authorization.
*Members seeking information on sterilization services, hysterectomies (for sterilization purposes), and abortions should call AmeriHealth Caritas Louisiana. Abortion and sterilization services require prior authorization by AmeriHealth Caritas Louisiana. A representative will make necessary arrangements for members eligible for these services. However, members seeking information on hysterectomies for medical reasons not related to sterilization may contact Member Services at 1-888-756-0004.
Services that do not require prior authorization
- Emergency room services (in-network and out-of-network)
- 30-Hour observations (except for Maternity – notification required)
- Dialysis services
- Low-level plain films - X-rays, EKGs
- Family planning services
- Post stabilization services (in-network and out-of-network)
- EPDST screening services
- Women's health care by in-network providers (OB-GYN services)
- Continuation of covered services for a new member transitioning to the plan the first 30 calendar days of continued services
- Routine vision services
Service for which notification is requested
- Maternity obstetrical services (after the first visit) and outpatient care (includes 30-hour observations)
- All newborn deliveries
Members with Medicare coverage may go to Medicare health care providers of choice for Medicare covered services, whether or not the Medicare health care provider has complied with AmeriHealth Caritas Louisiana's prior authorization requirements. AmeriHealth Caritas Louisiana's policies and procedures must be followed for non-covered Medicare services.