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Preapproval/Precertification for Services

Commercial and Medicare Advantage members

Certain services require preapproval/precertification from AmeriHealth prior to being performed.

If your patient needs services that require preapproval/precertification, please call 1-800-275-2583. Providers registered with the NaviNet® web portal may submit requests electronically for services to be rendered at an acute care facility or ambulatory surgical center.

The Care Management and Coordination (CMC) department will evaluate your request and will notify your office once a decision has been reached for those cases that require clinical review. You will be provided with a preapproval/precertification reference number based on the determination of your request. Failure to complete required preapproval/precertification may result in a reduction in payment or nonpayment for the services not preapproved/precertified.

Your office or your patient may appeal our decision or provide additional information to support the request at any time during the evaluation process. Please refer to the CMC section of the Provider Manual for Participating Professional Providers for more information.

Services that require preauthorization

Delaware

Pennsylvania

Individual Products

Employer Group Products

New Jersey

51+ Plans

Small Employer Health (SEH) Plans

Individual Health Plans (also called IHC)

Note: Some preapproval/precertification product lists include 51+ and Small Employer Health (SEH) references. Please note the following:

  • 51+ refers to group coverage for businesses with more than 50 employees;
  • SEH refers to group coverage for businesses with fewer than 50 employees.

Services that do not require precertification

PDF icon Services that do not require precertification

Medicare Part B drugs that require preauthorization

PDF icon AmeriHealth 65® NJ HMO

For additional benefits where precertification may be required, please refer to the following:

PDF icon AmeriHealth 65 NJ Medical-Only HMO

PDF icon AmeriHealth 65 NJ Rx HMO

Note: This information is updated regularly but is subject to change. For the most up-to-date information, please contact Customer Service at 1-800-275-2583. Information about services that require preauthorization can also be obtained using NaviNet.