Some services and medicines need to be approved as “medically necessary” by AmeriHealth Caritas Pennsylvania (PA) Community HealthChoices (CHC) before your PCP or other health care provider can help you to get these services. This process is called “prior authorization.”
Prior authorization process
- Your PCP or other health care provider must give AmeriHealth Caritas PA CHC information to show that the service or medication is medically necessary.
- AmeriHealth Caritas PA CHC nurses review the medical information. The nurses use clinical guidelines approved by the Department of Human Services to see if the service or medication is medically necessary.
- If the request cannot be approved by an AmeriHealth Caritas PA CHC nurse, an AmeriHealth Caritas PA CHC doctor will review the request.
- If the request is approved, we will let you and your health care provider know it was approved.
- If the request is not approved, a letter will be sent to you and your health care provider telling you the reason for the decision.
- If you disagree with the decision, you may file a complaint or grievance and/or request a Fair Hearing. See complaints, grievances and fair hearings for more information.
- You may also call Participant Services for help in filing a complaint, grievance and/or fair hearing.
For a complete list of services, items, or medicines that need prior authorization, please see the Participant Handbook. If you have questions about the prior authorization process, please talk with your doctor. You can also call Participant Services at 1-855-235-5115 (TTY 1-855-235-5112).
You may have to pay when:
- A service is provided without prior authorization when prior authorization is required.
- A service is provided by a provider who is not in the AmeriHealth Caritas Pennsylvania Community HealthChoices network and prior authorization was not given to see this provider (except for emergency services; family planning services; and any Medicare-covered services from a Medicare provider if you have Medicare coverage*).
- The service provided is not covered by AmeriHealth Caritas Pennsylvania Community HealthChoices and your provider told you that it is not covered before you received the service.
Your health care provider can also bill you for copays that were not paid at the time you received the service. Learn what to do if you get a bill or statement and review the copayment schedule (PDF).