Prior Authorization Lookup Tool

Find out if a service needs prior authorization. Type a Current Procedural Terminology (CPT) code or a Healthcare Common Procedure Coding System (HCPCS) code in the space below to get started.

Important notice

This tool provides general information for outpatient services performed by a participating provider.

The following services always require prior authorization:

  • Elective inpatient services
  • Urgent inpatient services
  • Services from a nonparticipating provider. (Join Our Network.)

If you have questions about this tool or a service, or to obtain an authorization, contact Utilization Management at 1-833-702-2262 or fax to the appropriate number below:

  • Physical Health: 1-844-412-7890.
  • Behavioral Health: 1-855-243-6352.

Vendor authorization rules

For codes that are delegated to a third-party vendor, codes requiring authorization are listed in the following document: Evolent (formerly National Imaging Associates) Utilization Review Matrix 2024

Directions

  1. Enter a CPT/HCPCS code in the space below.
  2. Click Submit.
  3. The tool will tell you if that service needs prior authorization.

DISCLAIMER

The following attempts to provide the most current information for the Prior Authorization Lookup Tool. Please note that this information may be subject to change, and a prior authorization is NOT a guarantee of payment. Payment is dependent on a number of factors, including but not limited to member eligibility on the date of service, coverage limitations and exclusions, provider contracts, and correct coding and billing for the services at issue. AmeriHealth Caritas Next reserves the right to adjust any payment made following a review of the medical records and determination of medical necessity for the services rendered. All non-participating providers must submit requests for prior authorization, except as may be required by law. For additional details, or if you are uncertain that prior authorization is needed, please see the Provider Manual on the AmeriHealth Caritas Next website.

For Providers