Prior Authorization
The following services always require prior authorization:
- Elective inpatient services
- Urgent inpatient services
- Services from a non-participating provider
All results are subject to change in accordance with plan policies and procedures and the provider manual (PDF).
Get specialty prior authorization forms.
Complete the medical prior authorization form (PDF).
Online
For online prior authorization, providers can use the Medical Authorizations feature inside our secure provider portal (NaviNet) by going to https://www.navinet.net.
In addition to submitting new requests and inquiring about 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.
By fax
Medical authorization and other forms are available here.
- Fax the medical prior authorization form (PDF) to 202-408-1031 or 1-877-759-6216.
- Fax the behavioral health prior authorization request form to 1-855-410-6638.
By phone
- Call our Utilization Management department at 202-408-4823 or 1-800-408-7510. Our clinical staff and medical directors are available from 8 a.m. to 5:30 p.m., Monday to Friday, except for company-observed holidays.
- A toll-free fax line is available to receive inbound communication 24 hours a day, seven days a week. Communications received after normal business hours are returned on the next business day, and communications received after midnight from Monday to Friday are responded to on the same business day.
- To contact the Behavioral Health Utilization Management team directly, please call 1-877-464-2911.
- 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 https://www1.radmd.com. View the utilization review matrix (PDF) here.
Organ transplant initial evaluation notification
Use the following information to help with the submission of notification for organ transplant evaluations:
- Providers will submit the transplant evaluation notification via the NaviNet provider portal using the Medical Authorizations link, located under Workflows for AmeriHealth Caritas DC.
- Under Service Type, choose Outpatient Transplant Evaluation from the dropdown.
- Medical necessity review will not be required for the initial evaluation.
- Medical necessity review will be required prior to the transplant procedure.
- For organ transplants, contact the Utilization Management transplant team at 1-833-983-7229 from 8 a.m. to 5 p.m., Monday to Friday. Note: Messages will be monitored seven days a week.
After hours, weekends, and holidays
After business hours, on weekends, and on holidays, health care providers, practitioners, and enrollees may contact the Utilization Management department through Enrollee Services at 202‑408‑4720 or 1‑800‑408‑7511.
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.
- 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.
- 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.
- 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).
- 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.
- 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 that 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
- 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 to save the life of the mother or prevent long-lasting physical health damage if the pregnancy is carried to term, or in cases of rape or incest.
- 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.
Resources and Guides
- NaviNet Medical Authorizations Training Guide (PDF)
- NaviNet Medical Authorizations Frequently Asked Questions (FAQ) (PDF)
- Ways to Avoid Common Errors in Electronic Prior Authorization Submissions
- Tutorial Video – Prior Authorization Inquiry Process
- Tutorial Video – Prior Authorization Submission Process