Physical Health Prior Authorizations

AmeriHealth Caritas Delaware providers may need to complete a prior authorization request form (PDF) before administering some health services to members.

Submit a prior authorization request for physical health services

By phone

  • Call our Utilization Management department at 1-855-396-5770, from 8 a.m. to 5 p.m., Monday to Friday.

By fax

  • Fax to 1-866-497-1384.

Physical health services that require prior authorization

  • All out-of-network services, excluding emergency services.
  • All services that may be considered experimental and/or investigational.
  • All miscellaneous, unlisted, or not otherwise specified codes.
  • All services not listed on the AmeriHealth Caritas Delaware Fee Schedule.
  • Out-of-network specialty visits.
  • Elective air ambulance.
  • Inpatient services:
    • All inpatient hospital admissions, including medical, surgical, and rehabilitation services.
    • Obstetrical admissions and newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after cesarean section.
    • Inpatient medical detoxification.
    • Elective transfers for inpatient and/or outpatient services between acute care facilities.
    • Long-term acute care, skilled nursing facility, and rehabilitation placement.
  • Gastroenterology services (codes 91110 and 91111 only).
  • Gender reassignment services.
  • Genetic testing.
  • Home-based services:
    • Home health care.
    • Private-duty nursing, if covered under benefit category.
    • Skilled nursing visits.
    • Speech, physical, and occupational therapy.
  • Enteral feedings.
  • Hospice inpatient services.
  • 17-P or Makena infusion for pregnancy-related complications.
  • Contact PerformRx for prior authorization requirements.
  • Termination of pregnancy.
  • Therapy and related services.
  • Speech, occupational, and physical therapy (after 24 visits for each modality).
  • Cardiac rehabilitation and pulmonary rehabilitation.
  • Transplants, including transplant evaluations.
  • All durable medical equipment (DME) rentals, and:
    • Repairs for purchased DME items or equipment.
    • For billed charges $500 and over, including prosthetics and orthotics.
    • Incontinence products (such diapers and pull-ups):
      • Authorization is required for quantity limits exceeding eight products per day (240 per 30-day month supply).
    • The purchase of all motorized wheelchairs and all wheelchair components.
    • Use of standard or non-customized DME during a facility stay would be considered part of the per diem payment for the facility (such as a standard wheelchair). Any DME that requires customization would not be regularly owned by a facility or is for use by a member on discharge from a facility would be subject to evaluation for medical necessity similar to DME in any other setting.
  • Hearing services and devices (these may include, but are not limited to, FM systems and cochlear implants/devices) with a purchase price that exceeds the limits noted below: 
    • Monaural hearing aids costing more than $500.00.
    • Binaural hearing ads costing more than $500.00.
  • Replacement of hearing aides that are less than four years old, except for children under 21.
  • Vision services: Contact Avesis via email at visionum@avesis.com or fax at 1-855-591-3566.
  • Hyperbaric oxygen.
  • Gastric restrictive procedure and surgeries.
  • Surgical services that may be considered cosmetic, including:
    • Blepharoplasty.
    • Mastectomy for gynecomastia.
    • Mastopexy.
    • Maxillofacial.
    • Panniculectomy.
    • Penile prosthesis.
    • Plastic surgery or cosmetic dermatology.
    • Reduction mammoplasty.
    • Septoplasty.
  • Inpatient hysterectomies.
  • Cochlear implantation.
  • Pain management.
  • The following radiology services, when performed as an outpatient service, require prior authorization by AmeriHealth Caritas Delaware's radiology benefits vendor, National Imaging Associates Inc. (NIA):  
    • Computed tomography (CT) scan.
    • Positron emission tomography (PET) scan.
    • Magnetic resonance imaging (MRI).
    • Magnetic resonance angiography (MRA).
    • Nuclear cardiac imaging.

To request prior authorization, contact NIA via their provider web portal or by calling 1-800-424-4791, from Monday to Friday, 8 a.m. to 8 p.m. ET.

Ordering providers

  • To initiate a request for an authorization, please visit NIA's website, or call toll free at 1-800-424-4791. 
  • To check the status of an authorization, please visit NIA's website, or call the interactive voice response (IVR) system at 1-800-424-4791.

Rendering providers

  • To initiate a request for an authorization, please visit NIA's website, or call toll free at 1-800-424-4791.

NIA Frequently Asked Questions (FAQs) for Providers (PDF)

Physical health services that require notification

Providers will be asked to notify AmeriHealth Caritas Delaware when the following services are delivered:

  • Maternity obstetrical services (after the first visit) and outpatient care (including 48-hour observations).
  • All newborn deliveries.
Providers