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.
- The searchable formulary 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 formulary may not apply. If you have questions about drug coverage, please call 1-800-684-5502.
- Drugs administered by physician or outpatient hospitals on the Louisiana Medicaid Fee Schedule will be reimbursed. Refer to the list of HCPCS codes to see which drugs require prior authorization.
Services requiring prior authorization
- Behavioral codes requiring authorization (PDF).
- Codes requiring authorization (PDF).
- HCPCS 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 (except emergency room services, urgent care facilities, family planning services, EPSDT preventive routine screenings, post stabilization services, and continuity of care services for new enrollees).
- Air ambulance.
- Once per lifetime procedures performed a second time.
- Inpatient services:
- All inpatient hospital admissions, including medical, surgical, and rehabilitation.
- Obstetrical admissions/newborn deliveries exceeding 72 hours after vaginal delivery and 120 hours after caesarean section.
- Inpatient 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 physical therapy (PT), occupational therapy (OT), speech therapy (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.
- Enteral feedings, including related durable medical equipment (DME).
- Hospice services.
- HPV immunizations for members finishing the series at 27 years of age.
- Therapy and related services:
- ST, OT, and PT at a free-standing facility (private office/rehab clinic) require prior authorization at first visit for all visits (only covered for members under 21). Initial evaluations and re-evaluations (every six months) do not need prior authorization; however, any additional evaluations outside of those parameters would require a prior authorization.
- Hospital-based ST, OT, and PT — require prior authorization for all visits. Initial evaluations and re-evaluations (every six months) do not need prior authorization. Any additional evaluations outside of those parameters would require prior authorization.
- Chiropractic care (covered for ages 0 – 20).
- Cardiac rehabilitation.
- Transplants, including transplant evaluations.
- All DME rentals.
- DME custom orthotics and prosthetics.
- All wheelchair parts.
- 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: Prior authorization requirements are based upon the medication's HCPCS code (PDF) instead of the billed amount.
- Cochlear implantation (covered for members under age 21).
- 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.
- PET 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.
Services that do not require prior authorization
- Emergency room services and urgent care facilities (in-network and out-of-network).
- Sterilizations (tubal ligations or vasectomies in-network).
- 48-hour observations (in-network).
- Dialysis services rendered at freestanding or hospital-based outpatient dialysis facilities (which would include supplies used at the facilities for the dialysis).
- Low-level plain films — X-rays, EKGs.
- Family planning services (in-network and out-of-network).
- 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.
- DME billed charges under $750 (except custom orthotics and prosthetics which would require an authorization regardless of the billed amount). 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).
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.