Prior Authorizations

Services requiring prior authorizations are subject to change.

A member does not need prior authorization for emergency services or to see a primary care physician. AmeriHealth Caritas Next does not require referrals for any service.

Physical Health and Behavioral Health Prior Authorization

Prior Authorization Lookup Tool

Use our Prior Authorization Lookup Tool to find out if a service requires prior authorization.

Submit a prior authorization request for physical health or behavioral health services:

Online

For online prior authorization, providers can use the Medical Authorizations feature inside our secure provider portal (NaviNet) by going to https://www.navinet.net.

In addition to submitting and inquiring on existing Authorizations, you will also be able to:

  • Verify if No Authorization is Required.
  • Receive Auto Approvals, in some circumstances.
  • Submit Amended Authorization.
  • Attach supplemental documentation.
  • Sign up for in-app status-change notifications directly from the health plan.
  • Access a multi-payer Authorization log.
  • Submit inpatient concurrent reviews online if you have Health Information Exchange (HIE) capabilities. (Fax is no longer required.)
  • Review inpatient admission notifications and provide supporting clinical documentation.

Video tutorials and step-by-step instructions will be available via the NaviNet Plan Central page and the NantHealth Help Center.

AmeriHealth Caritas Next will offer training on the NaviNet Medical Authorizations system. Contact your Provider Network Management Account Executive for available training dates and times.

By fax

Physical Health Prior Authorization (PDF) and Behavioral Health Prior Authorization (PDF) are available in the forms section of the website.

  • Fax the Physical Health Prior Authorization form to 1-844-412-7890.
  • Fax the Behavioral Health Prior Authorization form to 1-855-243-6352.
By phone

Call our Utilization Management department at 1-833-702-2262 from 8 a.m. to 5 p.m., Monday to Friday.

After hours, weekends, and holidays

After business hours, on weekends, and on holidays health care providers, practitioners, and members may contact the UM department through the plan Member Services at 1-833-613-2262 (TTY 1-844-214-2471).

The UM Department maintains a UM Reviewer and a Medical Director after business hours, on weekends, and on holidays observed by AmeriHealth Caritas Family of Companies business operations for urgent medical necessity determinations.

A toll-free fax line is available to receive inbound communication 24 hours a day, 7 days a week. Communications received after normal business hours are returned on the next business day, and communications received after midnight on Monday to Friday are responded to on the same business day.

Pharmacy Prior Authorization

Use the following information to help you with pharmacy prior authorizations:

Online

Pharmacy prior authorizations can be found online on the PerformRxSM website.

By phone

Call our Provider Services department at 1-844-280-9131 from 8 a.m. to 6 p.m., Monday to Friday.

By fax

The Pharmacy Prior Authorization form (PDF) is available in the forms section of the website. For medical pharmacy drug prior authorization requests, please complete the Healthcare Common Procedure Coding System (HCPCS) Authorization Form (PDF).

Fax to 1-855-756-9901.

For pharmacy prior authorizations after business hours, weekends, and holidays, please call the 24/7 Pharmacy Member Services number at 1-844-211-0968.

For Providers