Prior Authorization requirements
To request or check the status of a prior authorization request or decision for a particular plan member, access our Interactive Care Reviewer (ICR) tool via Availity. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate.
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Behavioral health
Fax all requests for services that require prior authorization to:
Inpatient:
1-877-434-7578
Outpatient:
1-800-505-1193
Services billed with the following revenue codes always require prior authorization:
| 0240–0249 | All-inclusive ancillary psychiatric |
| 0901, 0905–0907, 0913, 0917 | Behavioral health treatment services |
| 0944–0945 | Other therapeutic services |
| 0961 | Psychiatric professional fees |
Pharmacy
Services billed with the following revenue codes always require prior authorization:
| 0632 | Pharmacy multiple sources |
Medicare or long-term services and supports
Medicare
Precertification is not required for physician Evaluation and Management services for members enrolled in the Amerivantage Balance (HMO) plan.
Long-term services and supports
All services require precertification:
- Personal care assistants: Call 1-732-452-6050 and select option 1 or fax requests to 1-888-240-4716
- Adult medical day care: Fax all requests to 1-888-240-4717
Personal care assistants:
1-732-452-6050
Adult medical day care:
1-888-240-4717
The following always require prior authorization:
Elective services provided by or arranged at nonparticipating facilities.
All services billed with the following revenue codes:
| 0023 | Home health prospective payment system |
| 0570-0572, 0579 | Home health aide |
| 0944–0945 | Other therapeutic services |
| 3101-3109 | Adult day and foster care |