When your primary care physician (PCP) thinks that you need specialized treatment, they can give you a referral (send you) to see a network specialist or certain other providers. For some types of referrals, your PCP may need to get approval in advance from our plan. This is called getting “prior authorization.” Prior authorization requirements for covered services are in italics in Section 4.2 (Benefits chart) of your Member Handbook (PDF).
For all services requiring prior authorization, your provider must request and receive prior authorization from AmeriHealth Caritas New Hampshire in order for you to get coverage for the service. If you do not get this authorization, AmeriHealth Caritas New Hampshire may not cover the service.
When making its coverage decision, AmeriHealth Caritas New Hampshire will consider whether the service is medically necessary.
AmeriHealth Caritas New Hampshire determines whether a service is "medically necessary" in a manner that is no more restrictive than the New Hampshire Medicaid criteria. For information about criteria used to support a medical necessity decision, call Member Services at 1-833-704-1177 (TTY 1-855-534-6730) for more information, or to request a copy of written rules specific to your situation.
In some cases, AmeriHealth Caritas New Hampshire will review medical necessity after covered services are delivered.
For members up to age 21 years “medically necessary” means the course of treatment:
- Is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that:
- Endanger life,
- Cause pain,
- Result in illness or infirmity;
- Threaten to cause or aggravate a handicap;
- Cause physical deformity or malfunction; and
- No other equally effective course of treatment is available or suitable for the member.
For members aged 21years and older, “medically necessary” means health care services that a licensed health care provider, exercising prudent clinical judgment, would provide, in accordance with generally accepted standards of medical practice to a member for the purpose of evaluating, diagnosing, preventing, or treating an acute or chronic illness, injury, disease, or its symptoms.
Medically necessary health care services for members ages 21 years and older must be:
- Clinically appropriate in extent, site, and duration;
- Consistent with the established diagnosis or treatment of the recipient’s illness, injury, disease, or its symptoms;
- Not primarily for the convenience of the member or the member’s family, caregiver, or health care provider;
- No more costly than other items or services which would produce equivalent diagnostic, therapeutic, or treatment results as related to the member’s illness, injury, disease, or its symptoms; and
- Not experimental, investigative, cosmetic or duplicative in nature.
To request preauthorization, you or your provider can contact AmeriHealth Caritas New Hampshire by:
- Calling Member Services at 1-833-704-1177 (TTY 1-855-534-6730)
- Mailing: AmeriHealth Caritas New Hampshire, P.O. Box 7386, London, KY 40742-7386
To get approval for these treatments or services, the following steps need to occur:
- AmeriHealth Caritas New Hampshire will work with your provider to collect information to help show us that the service is medically necessary.
- AmeriHealth Caritas New Hampshire nurses, doctors and behavioral health clinicians review the information. They use policies and guidelines approved by the New Hampshire Department of Health and 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, a letter will be sent to you and your health care provider giving the reason for the decision.
You can appeal any decision AmeriHealth Caritas New Hampshire makes. If you receive a denial and would like to appeal it, talk to your provider. Your provider will work with AmeriHealth Caritas New Hampshire to determine if there were any problems with the information that was submitted.
Service Authorization Requests for Children Under Age 21
Special rules apply to decisions to approve medical services for children under age 21 receiving Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services. Learn more about EPSDT services or call Member Services at 1-833-704-1177 (TTY 1-855-534-6730).
Getting authorization for out-of-network services
Read about how to get care from out-of-network providers.
If you are an American Indian or Alaska Native (AI/AN) of a federally recognized tribe or another individual determined eligible for Indian health care services, special coverage rules apply. You may get out-of-network services at an Indian health facility without prior authorization. Contact Member Services for more information at 1-833-704-1177 (TTY 1-855-534-6730).
Out-of-network hospital admissions in an emergency
The general rules for coverage of out-of-network care are different for emergency care. Read more about how to get care from out-of-network hospitals in an emergency and for post stabilization services.
Getting a second medical opinion
Members may receive a second opinion from a qualified health care professional within the network, or one may be arranged by AmeriHealth Caritas New Hampshire outside the plan’s network at no cost to you. If the provider is in the AmeriHealth Caritas New Hampshire provider network, you will not be charged for the second opinion. If you choose a provider who does not participate in the AmeriHealth Caritas New Hampshire network for the second opinion, the request to use the non-participating provider is subject to prior authorization review.
Preauthorization and time frames
We will review your request for a preauthorization within the following time frames:
- Standard review: We will make a decision about your request within 14 days after we receive it.
- Expedited (fast track) review: We will decide about your request and you will hear from us within three days.
- In most cases, if you are receiving a service and a new request is made to keep receiving a service, we must tell you at least 10 days before we change the service if we decide to reduce, stop or restrict the service.
If we approve a service and you have started to receive that service, we will not reduce, stop or restrict the service during the approval period unless we determine the approval was based on information that was known to be false or wrong.
- If we deny payment for a service, we will send a notice to you and your provider the day the payment is denied. These notices are not bills. You will not have to pay for any care you received that was covered by your plan or by Medicaid, even if your plan later denies payment to the provider.
If you have questions, call Member Services at 1-833-704-1177 (TTY 1-855-534-6730), 24 hours a day, seven days a week.
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.