Prior Authorization

NEW! Submit authorizations electronically

AmeriHealth Caritas Louisiana offers our providers access to Medical Authorizations for electronic authorization inquiries and submission. The Medical Authorizations portal is accessed through NaviNet and is located on the Workflows menu.

In addition to submitting and inquiring on existing authorizations, you will also be able to:

• Verify if no authorization is required
• Receive auto-approvals, in some circumstances
• Submit an amended authorization
• Attach supplemental documentation
• Sign up for in-app status-change notifications directly from the health plan
• Access a multi-payer authorization log
• Submit inpatient concurrent reviews online if you have Health Information Exchange (HIE) capabilities (Fax is no longer required.)
• Review inpatient admission notifications and provide supporting clinical documentation

Prior authorization and referral updates

• PCP to in-network specialists — no referral is required.
• Changes have been made to the Prior Authorization Service List (XLSX) (6/30/25), in accordance with LA Rev Stat § 46:460.54.
• Act 233 — Prior Authorization Service List (XLSX).

Medication requiring prior authorization

• Drugs requiring prior authorization or having any other restrictions are identified on the Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) (PDF)
• The LDH single PDL describes how medications are covered if the member were to receive them from an actual pharmacy. If the medication is normally administered by a health care professional and is reimbursed through “buy and bill,” then the prior authorization requirements listed in the printable and searchable drug list may not apply. If you have questions about drug coverage of medications, please call PerformRx at 1-800-684-5502.
• Provider-administered drugs may require prior authorization. The criteria for select provider-administered drugs can be found in the AmeriHealth Caritas Louisiana non-PDL prior authorization criteria (PDF).
• All written prior authorization requests for medications must be made using the Louisiana uniform prescription drug PA request form (PDF).

Services requiring prior authorization

AmeriHealth Caritas Louisiana has an agreement with Evolent [formerly National Imaging Associates, Inc. (NIA)], to manage diagnostic imaging services such as MR/CT/PET. The program will require prior authorization from Evolent for nonemergent outpatient:

• CT/CTA
• CCTA
• MRI/MRA
• PET scan
• MUGA scan
• Myocardial Perfusion Imaging (MPI)

The physician ordering the procedures noted above is responsible for obtaining prior authorization. The rendering facility must ensure that prior authorization was obtained. We recommend that you develop a process to ensure that the appropriate authorization number(s) has been obtained. Payment to the ordering physician and rendering facility will be denied for procedures performed without necessary authorization.

Providers can request prior authorization via the internet at https://www1.radmd.com or by calling Evolent at 1-800-424-4897.

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 provider. However, the ordering provider 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.)

Services that do not require prior authorization

• Continuation of covered services for a new member transitioning to the plan the first 30 calendar days of continued services (in network and out of network).
• Dialysis services rendered at freestanding or hospital-based outpatient dialysis facilities, including supplies used at the facilities for the dialysis (in network).
• Durable medical equipment (DME) — a billed charge under $750 (in network), except for the following:
  • Custom orthotics and prosthetics
  • Diapers/pull-ups (ages 4 – 20) for those who qualify:
       - Quantities over 200 per month for either or both
       - Brand-specific diapers
  • Rentals
  • Wheelchair parts

Note: The provider must be credentialed to provide DME services, except for podiatrists. For a list of DME codes that podiatrists are allowed to bill without being credentialed as a DME provider, please refer to the Claims Filing Instructions Manual (PDF).

• Early and Periodic Screening, Diagnostic, and Treatment (EPDST) screening services (in network and out of network)
• Emergency room services (in network and out of network)
• Family planning services (in network and out of network)
• Low-level plain films — X-rays, electrocardiograms (in network)
• Inpatient imaging procedures
• Observation – 48 hours (in network)
• Post-stabilization services (in network and out of network)
• Routine vision services (in network)
• Sterilization (in network)
• Urgent care facilities (in network and out of network)
• Women's health care/OB/GYN services (in network)

Service for which notification is required

• 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.