Prior Authorization

Prior authorization requests may be submitted to the Utilization Management (UM) department.

• The UM department hours of operation are 8 a.m. – 5:30 p.m., Monday through Friday
• Requests can be submitted through NaviNet
• Requests can be made by telephone: 202-408-4823 or 1-800-408-7510
• Requests can be made by fax: 202-408-1031 or 1-877-759-6216
• To contact the Behavioral Health Utilization Management team directly, please call 1-877-464-2911 or email to integratedbhumopt@amerihealthcaritas.com
• The review of prior authorization requests for radiology services has been delegated to Evolent (formerly National Imaging Associates, Inc.); those requests must be directed to 1-877-517-9177 or www.radmd.com
• Utilization review matrix (PDF)

The following services require prior authorization review for medical necessity and place of service:

• Elective or non-emergent air ambulance transportation
• All out-of-network services, except for emergency services for AmeriHealth Caritas District of Columbia (DC) Medicaid enrollees. Note: All out-of-network services are excluded from coverage for AmeriHealth Caritas DC Alliance enrollees.
• Inpatient services
• All inpatient hospital admissions, including medical, surgical, and rehabilitation
• Obstetrical admissions and newborn delivery care that exceeds 48 hours after vaginal delivery and 96 hours after caesarean section. Delivery admissions are excluded from coverage for AmeriHealth Caritas DC Alliance enrollees.
• Elective transfers for inpatient and/or outpatient services between acute care facilities
• Long-term acute care
• Long-term care (for up to 30 consecutive days)
• Home-based services:
  • Home health care after 18 visits per calendar year for therapies and/or skilled nurse visits
  • Home health aides from start of service
  • Personal care services provided by qualified individuals (not family members) in the home when deemed medically necessary. Personal care services are excluded from coverage for AmeriHealth Caritas DC Alliance enrollees.
  • Private-duty nursing services
  • Enteral feedings, including related durable medical equipment (DME)
• Therapy and related outpatient services:
  • Speech therapy, occupational therapy, and physical therapy with the first visit for each modality in hospital outpatient settings. In all other settings or places of services, prior authorization is required for these services after 12 visits.
  • Cardiac and pulmonary rehabilitation, from first visit
• Transplant surgery — organ, stem cell, and tissue — must be approved by DC Medicaid fee-for-service (FFS). Transplants are excluded from coverage for AmeriHealth Caritas DC Alliance enrollees.
• All DME rentals in excess of $750/month
• DME purchases for billed charges $750 and over, including prosthetics and orthotics
• Repairs for purchased DME items and equipment
• Hearing services and devices that exceed $750 purchase price, including hearing aids, FM systems, and cochlear implants and devices. Hearing services and devices are excluded from coverage for AmeriHealth Caritas DC Alliance enrollees ages 21 years and older.
• Diapers and pull-up diapers for ages 3 years and older:
  • 200 or more per month, for either or both
  • Brand-specific diapers
• Joint and spine surgery
• Diagnostic sleep testing
• Medical oncology
• Genetic testing
• Radiation oncology
• Hyperbaric oxygen
• Gastric restrictive procedures or surgeries
• 17-P and Makena® infusion for pregnancy-related complications
• Gastroenterology services (codes 91110 and 91111 only)
• Surgical services that may be considered cosmetic, such as:
  • Blepharoplasty
  • Mastectomy for gynecomastia
  • Mastopexy
  • Maxillofacial surgery
  • Panniculectomy
  • Penile prosthesis
  • Plastic surgery or cosmetic dermatology
  • Reduction mammoplasty
  • Septoplasty
• Inpatient hysterectomy
• Elective terminations of pregnancy
• Pain management — external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, and nerve blocks
• Select radiological exams as outlined below. This excludes radiological studies that occur during inpatient, emergency room, and/or observation stays.
  • Positron emission tomography (PET) scans
  • Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA)
  • Nuclear cardiology diagnostic testing
  • Computed tomography (CT/CAT) scans and CT angiography
• All miscellaneous unspecified codes
• All services that may be considered experimental or investigational
• All services not listed on the DC Medicaid fee schedule
• Behavioral health care:
  • Mental health partial hospitalization programs
  • Inpatient detoxification admissions
  • Mental health inpatient admissions
  • Neuropsychological testing
  • Psychological testing
  • Developmental testing
  • Behavioral health day treatment
  • Residential treatment
  • Electroconvulsive therapy

• Obstetrical services after the first visit and outpatient care, including 30-hour observations
• Normal newborn deliveries
• No authorization is required for initial 10 sessions of behavioral health outpatient therapy (individual, family, or group) per enrollee. Notification is required within 10 days of initiating treatment.

• Emergency room services, in network and out of network
• 48-hour observations, except for maternity, which requires notification
• Low-level plain films, such as X-rays and electrocardiograms (EKGs)
• Family planning services
• Post-stabilization services, in network and out of network
• Early and periodic screening, diagnostic, and treatment (EPDST) services
• In-network obstetric and gynecological (OB/GYN) services
• Emergency services, excluding AmeriHealth Caritas DC Alliance enrollees, who are covered by DC Medicaid FFS
• Women’s health specialist services (to provide women’s routine and preventive health care services)
• Diagnosis and treatment of sexually transmitted diseases and other communicable diseases, such as tuberculosis and HIV/AIDS, as determined by county health departments
• OB/GYN services for one annual visit and any medically necessary follow-up care for detected conditions. The enrollee must use an AmeriHealth Caritas DC provider for these services.
• Podiatry and some dermatology services. The enrollee must use an AmeriHealth Caritas DC provider for these services.
• Immunizations by county health departments and participating primary care providers
• Imaging procedures related to emergency room services, observation care, and inpatient care
• Outpatient therapy — individual, family, or group — after the initial 10 sessions
• Behavioral health counseling and therapy

• Chiropractic services
• Infertility treatment
• Sterilizations for persons under age 21
• Sterilization reversals
• Cosmetic surgery
• Experimental or investigational services, surgeries, treatments, and medications
• Services that are part of a clinical trial protocol
• Abortion, unless medically necessary
• Services that are not medically necessary and/or that are not described as a covered service in the Provider Manual

*All requests for services are subject to District of Columbia Medicaid coverage guidelines and limitations.

• Screening and stabilization services for emergency medical care provided outside the District or by an out-of-network facility
• Emergency services billed with any diagnosis code on the District emergency services list
• Services furnished in schools
• Out-of-network services
• Services and supplies related to surgery and treatment for temporomandibular joint (TMJ) problems
• Newborn deliveries (Pregnant enrollees are encouraged to contact the appropriate District agency to determine eligibility for Medicaid.)
• Chiropractic services
• Cosmetic surgery
• Open heart surgery
• Organ transplantation
• Sclerotherapy
• Treatment for obesity
• Abortion, unless medically necessary
• Experimental treatment and/or investigational services and items
• Infertility treatment
• Sterilization reversals
• Outpatient mental health and substance use services
• Inpatient mental health and substance use services, except services related to medical treatment received in a hospital for life-threatening withdrawal from alcohol or narcotic drugs
• Vision services (for enrollees over 21 years old)
• Hearing services and devices (for enrollees over 21 years old)
• Personal care services
• Private duty nursing
• Non-emergency medical transportation
• Services that are not medically necessary and/or that are not described as a covered service in the Provider Manual

Note: Some excluded services may be covered through DC Medicaid FFS.

*All requests for services are subject to District of Columbia Medicaid coverage guidelines and limitations.

AmeriHealth Caritas District of Columbia offers our providers access to medical authorizations for electronic authorization inquiries and submission. The medical authorizations portal is accessed through NaviNet 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 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