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Physical Health Prior Authorizations

AmeriHealth Caritas Iowa providers may need to complete a prior authorization request form (PDF) before administering some health services to members.

How to submit a prior authorization request for physical health services

By phone

  • Call our Utilization Management department at 1-844-411-0604, 8:30 a.m. to 5 p.m., Monday through Friday.

By fax

  • Fax to 1-844-399-0478.

Physical health services that require prior authorization

AmeriHealth Caritas Iowa requires prior authorization for the following services:

  • All out of network services (with the exceptions noted below).
  • All services that may be considered Experimental and/or Investigational.
  • Out-of-network specialty visits.
  • Air ambulance.
  • In-patient services
    • All inpatient hospital admissions, including medical, surgical and rehabilitation.
    • Obstetrical admissions/newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after caesarean section.
    • In-patient medical detoxification.
    • Elective transfers for inpatient and/or outpatient services between acute care facilities.
    • Long-term care initial placement if still enrolled with the health plan.
  • Genetic testing.
  • Home-based services
    • Home health care.
    • Private duty nursing and personal care services if covered under benefit category.
    • Skilled nursing visits (after six visits).
    • Enteral feedings, including related durable medical equipment (DME).
  • Hospice inpatient services.
  • Termination of pregnancy
    • Must meet indications based on Iowa DHS guidelines and requirements:
  1. The physician certifies that the pregnant woman's life would be endangered if the fetus were carried to term.
  2. The physician certifies that the fetus is physically deformed, mentally deficient or afflicted with a congenital illness and the physician states the medical indication for determining the fetal condition.
  3. The pregnancy was the result of a rape reported to a law enforcement agency or public or private health agency which may include a family physician within 45 days of the date of occurrence of the incident. The report shall include the name, address, and signature of the person making the report. Form 470-0836 shall be signed by the person receiving the report of the rape.
  4. The pregnancy was the result of incest reported to a law enforcement agency or public or private health agency including a family physician no later than 150 days after the date of occurrence. The report shall include the name, address, and signature of the person making the report. Form 470-0836 shall be signed by the person receiving the report of incest.

(Source: 441-78.1(249A) Human Services Department Physicians' services).

  • Therapy and related services
    • Speech therapy, occupational therapy and physical therapy (after 12 visits per therapy per year).
    • Cardiac rehabilitation and pulmonary rehabilitation.
  • Transplants, including transplant evaluations.
  • All durable medical equipment (DME) rentals.
  • DME
    • For billed charges $750 and over, including prosthetics and orthotics.
    • Diapers/Pull-ups (ages 3 and above) who qualify:
      • For quantities more than 300 per month.
    • Use of standard or non-customized DME during a facility stay would be considered part of the per diem payment for the facility (such as a standard wheelchair). Any DME that requires customization, would not be regularly owned by a facility or is for use by a member on discharge from a facility would be subject to evaluation for medical necessity similar to DME in any other setting.
  • The purchase of all motorized wheelchairs and all wheelchair components.
  • Hearing services and devices that exceed $500 purchase price (may include but not limited to hearing aids, fm systems, and cochlear implants/devices).
  • Replacement of hearing aids less than four years old, except for children under 21.
  • Hyperbaric oxygen.
  • Gastric restrictive procedure/surgeries.
  • Surgical services that may be considered cosmetic, including:
    • Blepharoplasty.
    • Mastectomy for gynecomastia.
    • Mastopexy.
    • Maxillofacial.
    • Panniculectomy.
    • Penile prosthesis
    • Plastic surgery/cosmetic dermatology.
    • Reduction mammoplasty.
    • Septoplasty.
  • Inpatient hysterectomies.
  • Elective termination of pregnancy.
  • Cochlear implantation.
  • Pain management – external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and nerve blocks performed in a short procedure unit (SPU) or ambulatory surgery center (either hospital based or free standing) and pain management services not on the Iowa Medicaid Fee Schedule, performed in a physician office.
  • Radiology services
    • Computerized tomography (CT) scan.
    • Positron emission tomography (PET) scan.
    • Magnetic resonance imaging (MRI).
    • Magnetic resonance angiography (MRA).
    • Nuclear cardiac imaging.
  • All waiver services.
  • All unlisted and miscellaneous codes (including, but not limited, to codes ending in "99").
  • All HCBS Habilitation program services (Type 64).
  • All services not listed on Iowa Medicaid fee schedule.

Physical health services that require notification

Providers are asked to notify AmeriHealth Caritas Iowa when they deliver the following services to members:

  • Maternity obstetrical services (after the first visit) and outpatient care (includes 48-hour observations)
  • All newborn deliveries

Physical health services that do not require prior authorization

The following services do not require prior authorization from AmeriHealth Caritas Iowa:

  • Emergency room services (in-network and out-of-network).
  • 48-hour observations (except for maternity – notification required).
    • Chiropractic care — Services rendered beyond the limits below will be denied:
      • Category I diagnoses: 12 manipulations per 12-month period.
      • Category II diagnoses: 18 manipulations per 12-month period.
      • Category III diagnoses: 24 manipulations per 12-month period.
      • The utilization guideline for diagnostic combinations between categories is 28 manipulations per 12-month period.
  • Low-level plain films such as X-rays and electrocardiogram (EKG).
  • Family planning services.
  • Post-stabilization services (in-network and out-of-network).
  • Early and periodic screening, testing, and diagnosis (EPDST) screening services.
  • Women's health care by in-network providers (OB-GYN services).
  • Routine vision services.
  • Dialysis.