Part C coverage information
Understanding your health plan is very important. Review the information below to learn about your plan’s coverage and administration to make the best use of your benefits. To find out more about the benefits in your plan, simply log in at amerihealth.com/login.
Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCD)
The Company primarily relies on national coverage determinations (NCDs), local coverage determinations (LCDs), and other coverage guidance from the Centers for Medicare and Medicaid Services (CMS) and local Medicare contractors in the development of its Medicare Advantage medical policies. When Medicare coverage criteria are not fully established in applicable Medicare statutes, regulations, NCDs or LCDs, CMS allows Medicare Advantage plans to develop publicly accessible internal coverage criteria. The internal coverage criteria are based on current evidence in widely used treatment guidelines or clinical literature. Current, widely used treatment guidelines are those developed by organizations representing clinical medical specialties, and refers to guidelines for the treatment of specific diseases or conditions. Acceptable clinical literature includes large, randomized controlled trials or prospective cohort studies with clear results, published in a peer-reviewed journal, and specifically designed to answer the relevant clinical question, or large systematic reviews or meta-analyses summarizing the literature of the specific clinical question. For more information please see policies and guidelines.
Visit CMS.gov for more information on the CMS NCD.
View the AmeriHealth medical policy.
Organization determination (coverage decision) for Part C
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical items, services or drugs. In some cases, we might decide an item, service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. You, your physician, or your representative may make a written standard appeal request or oral or written expedited appeal request. When we give you our decision, we will use the standard deadlines unless we have agreed to use the expedited deadlines. A standard coverage decision means we will give you an answer within 7 days after we receive your doctor's statement. An expedited coverage decision means we will answer within 72 hours after we receive your doctor's statement. If the coverage decision is for a Part B drug (covered by your medical insurance not your drug coverage) and expedited, we will make a decision within 24 hours of us receiving the request, and if standard, we will make a decision within 72 hours of us receiving the request.
If you are an AmeriHealth Medicare PPO member, you can request a Part C organization determination by using one of the methods below.
- Phone: Call 1-866-569-5190 (TTY/TDD: 711). Calls to this number are free, 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
- Written: You need to follow specific instructions on how to submit a coverage decision request based on your health plan in writing. For more information, please reference your plan's Evidence of Coverage (EOC) or contact the Member Help Team. Written requests can be faxed to 1-888-289-3008.
If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form.
Organization determination instructions
You need to follow specific instructions on how to submit a coverage decision request based on your health plan. For more information, please reference your plan's EOC or contact the Member Help Team.
Prior authorization for Part C
Some of the services listed in the Medical Benefits Chart included in your plan's EOC are covered only if your doctor or other network provider gets approval in advance (also known as "prior authorization," "preapproval," or "precertification") from us. Your doctor or other network provider can request a medical prior authorization on your behalf. A decision on a request for prior authorization for medical services can take up to 7 days, if we are waiting for information from your doctor. If the prior authorization request is for a Part B drug and expedited, we will decision within 24 hours, and if standard, we will make a decision within 72 hours of us receiving the request.
You need to follow specific instructions on the prior authorization process and know what services require prior authorization based on your health plan. For more information, please reference your plan's EOC or contact the Member Help Team.
For AmeriHealth Medicare PPO, some in-network medical items and services are covered only if your doctor or other network provider gets prior authorization from our plan. In a PPO plan, you do not need prior authorization to obtain these out-of-network services, but and you can request prior authorization for these services to get them covered in advance.
Covered medical items and services, including durable medical equipment (DME), that may need approval in advance are marked in the Medical Benefits Chart by an asterisk.
For a list of covered medical services and durable medical equipment (DME) that need precertification/prior authorization in advance view the documents below:
- Precertification list (effective 1/1/2025)
Out-of-network coverage for Part C
For more information on out-of-network coverage for Part C, please reference your plan's EOC or contact the Member Help Team.
For claims and reimbursement
AmeriHealth Rx PPO Claims Receipt Center
PO Box 211184
Eagan, MN 55121
Y0041_H5361_AH_125392_M_2026
Website last updated: 8/15/2025