Sometimes AmeriHealth Caritas Iowa members might need prior authorization before they get a service. These services need to be approved as "medically necessary" by AmeriHealth Caritas Iowa. This needs to happen before your PCP or other health care provider can help you get these services.
As one of our members, you do not have to pay for medically necessary, covered services given by Iowa Medicaid providers.
AmeriHealth Caritas Iowa will honor your existing prior authorizations (pre-approvals) for benefits and services for the first 90 days at the time of your enrollment. If you have questions about prior authorization, please call Member Services at 1-855-332-2440.
Prior authorization process
- Your provider gives us information to show us the service requested is medically necessary .
- Our nurses and doctors review the information. They use rules approved by the Iowa Department of Human Services to see if the service is medically necessary.
- If the request is approved, we will let you and your health care provider know it was approved.
- If the request is not approved, we will send a letter to you and your health care provider telling you why.
You can appeal any decision we make. If you would like to appeal, talk to your provider. He or she will work with us to check if there were any problems with their submission.
You may also file a grievance or an appeal. You may apply for a state fair hearing if you disagree with the AmeriHealth Caritas appeals decision.
Services that need prior authorization
Some of the services that need preapproval are:
- All services you get out of the network (except for emergency care, post-stabilization and some family planning services).
Air ambulance for non-emergency needs.
- Cardiac rehabilitation.
- Pulmonary rehabilitation.
- Cosmetic surgery.
- Pull-on diapers* (ages 3 and up) of more than 300 per month. Note: when a combination of incontinence products is used, the benefit is limited to the maximum combined totals as outlined by Iowa Medicaid.
- *Diapers, briefs, panty liners and disposable underpads (e.g., Chux) are covered when:
- They are prescribed and determined to be appropriate for a member who has lost control over bowel or bladder function.
- A bowel or bladder training program was not successful.
- The member is 3 years old or older.
- (Coverage differs from Medicare.)
- Incontinence products are not covered for stress, urge or overflow.
- DME — all rentals.
- DME — purchases $750 and over.
- Inpatient hospital care.
- Home health care (after 6 visits).
- Hyperbaric oxygen.
- MRI, magnetic resonance angiogram (MRA), magnetic resonance stimulation (MRS), CT scan, nuclear cardiac imaging, PET scan and single-photon emission computerized tomography (SPECT) scan.
- Special Population Nursing Facility (aka Skilled Preapproval).
- Therapy and related services after 12 visits for:
- Speech therapy.
- Occupational therapy.
- Physical therapy.
- (Per calendar year for members 21 and older.)
- Waiver services.
This is not a full list. If you have questions, call Member Services at 1-855-332-2440 (TTY: 1-844-214-2471) 24 hours a day, 7 days a week. Or you can talk to your doctor.
Behavioral health services that need prior authorization
- Mental health partial hospitalization program.
- Mental health inpatient admissions.
- Neuropsychological testing.
- Psychological testing.
- Developmental testing.
- Behavioral health day treatment.
- Residential treatment (including crisis residential).
- Electroconvulsive therapy.
- Community-based outpatient services.
This is not a full list. If you have questions, call Member Services at 1-855-332-2440 (TTY: 1-844-214-2471) 24 hours a day, 7 days a week. Or, you can talk to your doctor.
You may have to pay for a service we do not cover. Your provider will ask you to sign an agreement to pay for the non-covered service.