Prior Authorizations

AmeriHealth Caritas New Hampshire providers must complete a Prior Authorization Request Form (PDF) before administering some health services to members.

Submit a prior authorization request for physical or behavioral health services

By phone

  • Call our Utilization Management department at 1-833-472-2264, from 8 a.m. to 5 p.m., Monday through Friday. For prior authorization after hours, on weekends, and during holidays, call Member Services at 1-833-704-1177.

By fax

Fax to 1-833-469-2264.

Services that require prior authorization

This list is subject to change. If you do not see the service you are seeking, please call Utilization Management at 1-833-472-2264 for the most up-to-date prior authorization information.

  • Air ambulance services.
  • All out-of-network services.
  • All unlisted miscellaneous and manually priced codes (including, but not limited to, codes ending in “99”).
  • Behavioral health services:
    • Mental health inpatient (IP) admissions.
    • Transcranial and vagus nerve stimulation.
    • Electroconvulsive therapy.
    • Mental health partial hospitalization program.
    • Mental health intensive outpatient program.
    • Psychological testing and neuropsychological testing.
  • Cochlear implantation.
  • Contact lenses (including dispensing fees).
  • Gastric bypass/vertical band gastroplasty.
  • Hyperbaric oxygen.
  • Hysterectomy (Hysterectomy Consent Form required).
  • Medicaid-covered abortions.
  • Implants (over $750), including, but not limited to, breast implants and pacemakers.
  • Intensive community-based services.
  • Transplants, including transplant evaluations.
  • Elective procedures, including, but not limited to, joint replacements, laminectomies, spinal fusions, discectomies, vein stripping, and laparoscopic/exploratory surgeries.

Plastic surgery

Surgical services that may be considered cosmetic, including, but not limited to:

  • Blepharoplasty.
  • Mastectomy for gynecomastia.
  • Mastopexy.
  • Maxillofacial (all codes applicable).
  • Panniculectomy.
  • Penile prosthesis.
  • Plastic surgery/cosmetic dermatology.
  • Reduction mammoplasty.
  • Septoplasty.
  • Breast reconstruction not associated with a diagnosis of breast cancer.

Durable medical equipment (DME)

  • Items with billed charges equal to or greater than $750.
  • DME leases or rentals and custom equipment.
  • Diapers/pull up diapers (for members age 3 and older) for amounts over the state published quantity limits.
  • Enteral nutritional supplements.
  • Prosthetics and custom orthotics.
  • All unlisted or miscellaneous items, regardless of cost.
  • Negative pressure wound therapy.

Inpatient

  • All inpatient hospital admissions, including medical, surgical, skilled nursing, long-term acute, and rehabilitation.
  • Behavioral health.
  • Obstetrical admissions for newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after cesarean section.
  • Medical detoxification.
  • Elective transfers for inpatient and/or outpatient services between acute care facilities.
  • Long-term care initial placement (while enrolled with the plan).

Home-based services

  • Home health care (physical, occupational, and speech therapy) and skilled nursing (after six combined visits, regardless of modality).
  • Home infusion services and injections (required from start of service) (see pharmacy list of HCPCS codes that require prior authorization).
  • Home health aide services (required from start of service).
  • Private duty nursing (extended nursing services) (required from start of service).
  • Personal care services (required from start of service).
  • Outpatient therapy (physical, occupational, or speech)
    • Prior authorization is required after the 12th visit per modality; benefit limit for members age 21 and older is 20 visits per modality per fiscal year. To help ensure you do not receive a denial for services because of failure to request prior authorization beginning with the 13th visit, we encourage you to notify us of the first 12 visits so we can track them in our system. You can notify us by calling 1-833-472-2264, faxing 1-833-469-2264, or submitting notification via the provider portal.

Pharmacy and medications

  • Contact PerformRxSM at 1-888-765-6394.

Pain management

  • External infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation, nerve blocks, and epidural steroid injections.

Advanced outpatient imaging services

The following services, when performed as an outpatient service, require prior authorization by AmeriHealth Caritas New Hampshire’s radiology benefits vendor, National Imaging Associates Inc. (NIA).

  • Nuclear cardiology.
  • Computed tomography angiography (CTA).
  • Coronary computed tomography angiography (CCTA).
  • Computed tomography (CT).
  • Magnetic resonance angiography (MRA).
  • Magnetic resonance imaging (MRI).
  • Myocardial perfusion imaging (MPI).
  • Positron emission tomography (PET).

To request prior authorization, contact NIA via their provider web portal  or by calling 1-800-424-4784, Monday through Friday, 8 a.m. to 8 p.m. ET.

Ordering providers

  • To initiate a request for authorization, please visit NIA's website, or call toll free at 1-800-424-4784
  • To check the status of an authorization, please visit NIA's website, or call the interactive voice response (IVR) system at 1-800-424-4784.

Rendering providers

  • To initiate a request for authorization, please visit NIA's website, or call toll free at 1-800-424-4784.

NIA Frequently Asked Questions (FAQs) for Providers (PDF)

NIA Utilization Review Matrix 2019 (PDF)

Services that require notification

Providers are asked to notify AmeriHealth Caritas New Hampshire when the following services are delivered:

For hospital providers who have members in an emergency room or medical unit while awaiting admission to a designated receiving facility or New Hampshire hospital, notification of the addition to the waitlist is required immediately by calling Member Services at 1-833-704-1177.

For certain behavioral health services, notification is required:

  • Crisis Intervention (PDF): Notification required within two business days after service.
  • American Society of Addiction Medicine (ASAM) levels of care: Notification is required at time of admission using the SUD Notification Form (PDF).
    • Level 1 — Withdrawal management: ambulatory withdrawal management without extended on-site monitoring.
    • Level 2 — Withdrawal management: ambulatory withdrawal management with extended on-site monitoring.
    • Level 2.1 — Substance use disorder (SUD) intensive outpatient services.
    • Level 2.5 — SUD partial hospitalization services.
    • Level 3.1 — Clinically managed low-intensity residential services.
    • Level 3.2 — Withdrawal management: clinically managed residential withdrawal management.
    • Level 3.3 — Clinically managed population-specific high-intensity residential services.
    • Level 3.5 — Clinically managed high-intensity residential services.
    • Level 3.7 — Medically monitored intensive inpatient services.
    • Level 4 — Medically managed intensive inpatient services.