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Preapproval/Precertification Requirements and Member Cost-Sharing

Commercial 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

Pennsylvania

Drug Cost-Sharing for Commercial Members

Members who are enrolled in Commercial FLEX products and certain customized plans are subject to applicable cost-sharing for select specialty injectable drugs. The list of these drugs is provided below.

NOTE: This list is subject to change. The member’s cost-sharing amount is based on the terms of the member’s benefit contract. Individual benefits should be verified. If you have questions about member cost-sharing, please contact Customer Service at 1-800-275-2583.