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
Services Requiring Prior Authorization
The following is a list of services requiring prior authorization review for medical necessity and place of service.
- In-patient services
- All inpatient 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 (after 6 visits for therapies and 6 visits for skilled nurse visits)
- Private Duty Nursing and Extended Home Health Services
- Private Duty Nursing (covered when medically necessary for under age 21)
- Home Health Extended Services (for under age 21)
- Therapy and related services
- Speech Therapy, Occupational Therapy and Physical Therapy (after 12 visits for each modality)
- Chiropractic Care
- Transplants, including transplant evaluations
- Injectable medications not listed on the Louisiana Medicaid Professional Services Fee Schedule are not covered by AmeriHealth Caritas Louisiana
- Air Ambulance
- Durable Medical Equipment. Prior Authorization is required for the following:
- Items with billed charges $500 and over, including prosthetics and orthotics
- All DME rentals
- All Enteral Nutritional Supplements and Supplies
- All Diapers/pull-up diapers for members ages 4 through 20 only. Not covered for members 21 and over and children under 3.
- All Wheelchair parts
- Medications: 17-P and all infusion/injectable medications listed on the Louisiana Medicaid Professional Services Fee Schedule with billed amounts of $250 or greater;
- Surgical services that may be considered cosmetic, including
- Mastectomy for Gynecomastia
- Penile Prosthesis
- Plastic Surgery/Cosmetic Dermatology
- Reduction Mammoplasty
- Cochlear Implantation (covered for members under 21)
- Gastric Bypass/Vertical Band Gastroplasty
- Pain Management – external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and nerve blocks.
- Services rendered the management of chronic pain are not covered.
- Radiology Services*: NIA Frequently Asked Questions
- 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, which 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 the Member Services Department at 888-756-0004.
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.