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 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 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. Use the Prior authorization lookup tool above to see if a code requires authorization.
Services requiring prior authorization
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.
- Cardiac rehabilitation
- Chiropractic care (only covered for ages 0 – 20 unless the member over 20 is in the AmeriHealth Caritas Louisiana Living Beyond Pain program and it would still require an authorization)
- Cochlear implants (only covered for members under age 21).
- DME for a billed charge of $750 and over
- DME custom orthotics and prosthetic
- DME (other):
- Diapers/pull-ups (ages 4-20) who qualify:
- Quantities over 200 per month for either or both
- Brand specific diapers.
- DME rentals.
- DME wheelchair parts.
- Gastric bypass/vertical band gastroplasty.
- Home-based services:
- Home health care- physical therapy (PT), occupational therapy (OT), speech therapy (ST), and skilled nursing visits (after 6 combined visits, regardless of modality).
- Private duty nursing/extended nursing services (only covered when medically necessary for ages 21 and under).
- Personal care services (only covered when medically necessary for ages 21 and under).
- Home health extended services.
- Home infusions and injections.
- Enteral feedings, including related DME.
- Hospice services.
- Hyperbaric oxygen therapy.
- Implants (billed charge of $750 and over).
- 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.
- Moderate sedation (ages 14 – 20).
- Once-in-a-lifetime procedures performed a second time.
- Outpatient therapy
- Speech therapy, occupational therapy, and physical therapy
- Initial evaluations or re-evaluations do not require prior authorization but are limited to every six months. Any additional evaluations or re-evaluations outside of those parameters would require prior authorization.
- Pain management – external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, and nerve blocks.
- Radiology services.*
- Surgical services that may be considered cosmetic, including:
- Mastectomy for gynecomastia.
- Penile prosthesis.
- Plastic surgery/cosmetic dermatology.
- Reduction mammoplasty.
- Transplants, including transplant evaluations.
*Prior authorization for CT scans, MRIs/MRAs, nuclear cardiology services and other radiology codes is required for outpatient services only. Please use the Prior authorization lookup tool above to see if a code requires authorization. The ordering provider 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 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.)
Emergency room, observation care, and inpatient imaging procedures do not require prior authorization.
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) who qualify:
- Quantities over 200 per month for either or both
- Brand-specific diapers
- 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).
- Observation – 48 hours (in network). All procedures (other than advanced imaging) that normally require an authorization still require an authorization if the admit to observation was not through the emergency room.
- 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.