Preapproval/Precertification for Services

Commercial Members

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

If your patient needs services that require preapproval/precertification, please contact our Health Resource Center at 1-800-275-2583. Providers registered with NaviNet^® 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.

The PDFs below include summaries of services that are subject to Preapproval/Precertification.

Delaware

• HMO/POS
• Flex
• PPO

Pennsylvania

• HMO/POS Standard
• Flex

New Jersey

51+ Plans

• AmeriHealth 51+ HMO
• AmeriHealth 51+ HMO (HMO Coinsurance)
• AmeriHealth 51+ HMO (HMO Split Copay)
• AmeriHealth 51+ HMO Plus
• AmeriHealth 51+ POS
• AmeriHealth 51+ POS (Insurance Company)
• AmeriHealth 51+ POS (Coinsurance)
• AmeriHealth 51+ POS Plus
• AmeriHealth 51+ POS Plus (POS Plus Coinsurance)
• AmeriHealth 51+ PPO
• AmeriHealth 51+ PPO HSA

Small Employer Health (SEH) Plans

• AmeriHealth SEH HMO
• AmeriHealth SEH HMO (Split Copay)
• AmeriHealth SEH HMO (Mandated HMO)
• AmeriHealth SEH HMO (Coinsurance)
• AmeriHealth SEH HMO Plus
• AmeriHealth SEH POS
• AmeriHealth SEH POS (Mandated - HMO Company)
• AmeriHealth SEH POS Plus
• AmeriHealth SEH PPO (Mandated)
• AmeriHealth SEH PPO HSA
• AmeriHealth SEH Open Access

Individual Health Plans (also called IHC)

• AmeriHealth HMO (IHC Standard)
• AmeriHealth HMO (IHC Basic and Essential)
• AmeriHealth HMO (IHC Preferred)

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.

List of Biotech/Specialty Injectables and Infusion Therapy drugs requiring precertification

Biotech/Specialty Injectable and Infusion Therapy Drugs

Medicare Members

To review the prior authorization requirements for Medicare Advantage members, please visit www.amerihealth65.com and select either a 2008 or 2009 health plan. After selecting the appropriate health plan, view the Summary of Benefits document.

Note: The information contained within these grids is intended as a high-level summary only. Content is updated regularly and subject to change. For the most up-to-date information, please contact Customer Service at 1-800-275-2583, prompt 2 for Provider Services. Information regarding services that require preapproval/precertification can also be obtained through NaviNet.