Prior Authorizations

Sometimes AmeriHealth Caritas Delaware members might need prior authorization before they get a service. These services need to be approved as "medically necessary" by AmeriHealth Caritas Delaware. This needs to happen before your primary care provider (PCP) or other health care provider can help you get these services.

As one of our members, you do not have to pay for medically necessary, covered services given by Delaware Medicaid providers.

AmeriHealth Caritas Delaware will honor your existing prior authorizations (pre-approvals) for benefits and services for the first 90 days at the time of your enrollment. If you have questions about prior authorization, please call AmeriHealth Caritas Delaware Member Services, 24 hours a day, seven days a week, at:

  • Diamond State Health Plan: 1-844-211-0966 (TTY 1-855-349-6281).
  • Diamond State Health Plan-Plus: 1-855-777-6617 (TTY 1-855-362-5769).

Prior authorization process

  1. Your provider gives us information to show us the service requested is medically necessary.
  2. Our nurses, doctors, and behavioral health clinicians review the information. They use rules approved by the Delaware Department of Health and Social Services to see if the service is medically necessary.
  3. If the request is approved, we will let you and your health care provider know it was approved.
  4. If the request is not approved, we will send a letter to you and your health care provider telling you why.

You can appeal any decision we make. If you would like to appeal, talk to your provider. Your provider will work with us to check if there were any problems with their submission.

You may also file a grievance or an appeal. You may apply for a state fair hearing if you disagree with the AmeriHealth Caritas Delaware appeal decision.

Services that need prior authorization

Some of the services that need preapproval are:

  • All services you get out of the network (except for emergency care, post-stabilization, and some family-planning services).
  • Cardiac rehabilitation.
  • Pulmonary rehabilitation.
  • Pull on diapers* (ages 4 and up). If the quantity exceeds the individual maximum allowed or any combination of maximum allowed for members over 4 years old as outlined by Delaware Medicaid.
  • Durable medical equipment (DME) rentals.
  • DME purchases of $500 and over.
  • Inpatient hospital care, including for behavioral health conditions.
  • Home health care (after six visits).
  • Hyperbaric oxygen.
  • Magnetic resonance imaging (MRI), magnetic resonance angiogram (MRA), and magnetic resonance stimulation (MRS).
  • Computerized tomography (CT) scan, nuclear cardiac imaging, positron emission tomography (PET) scan, and single-photon emission computerized tomography (SPECT) scan.
  • Special population nursing facility (skilled pre-approval).
  • Therapy and related services (after 24 visits for each therapy type per calendar year) for:
    • Speech therapy.
    • Occupational therapy.
    • Physical therapy.
  • Habilitation services.
  • Psychiatric inpatient hospitalization for members ages 18 and older. Inpatient behavioral health services for members under age 18 are managed by the Department of Services for Children, Youth, and Their Families (DSCYF).
  • Behavioral health partial hospitalization.
  • Behavioral health intensive outpatient program.
  • Behavioral health residential treatment facility, including the Institution for Mental Disease (IMD).
  • Substance use disorder (SUD) programs for all members ages 18 and older not enrolled in PROMISE with a behavioral health and/or SUD diagnosis. Prior authorization is required for:
    • Intensive outpatient program beyond 30 days.
    • Medically monitored inpatient treatment beyond 14 days.
    • Medically monitored withdrawal management inpatient treatment beyond five days. 
  • Electroconvulsive therapy (ECT).
  • Transcranial magnetic stimulation (TMS).
  • Vagus nerve stimulation (VNS).
  • Psychological and neuropsychological testing.

*Diapers, briefs, panty liners, and disposable underpads (e.g., Chux) are covered when:

  • They are prescribed and determined to be appropriate for a member who has lost control over bowel or bladder function.
  • A bowel or bladder training program was not successful.
  • The member is 4 years old or older. (Coverage differs from Medicare.)

This is not a full list. If you have questions, call Member Services 24 hours a day, seven days a week, at:

  • Diamond State Health Plan: 1-844-211-0966 (TTY 1-855-349-6281).
  • Diamond State Health Plan-Plus: 1-855-777-6617 (TTY 1-855-362-5769).

You may have to pay for a service we do not cover. Your provider will ask you to sign an agreement to pay for the non-covered service.

Members