Some services need to be approved as "medically necessary" by AmeriHealth Caritas Louisiana before your PCP or other health care provider can help you to get these services. This process is called "prior authorization."
Prior authorization process
- Your PCP or other health care provider must give AmeriHealth Caritas Louisiana information to show that the service or medication is medically necessary.
- AmeriHealth Caritas Louisiana nurses review the medical information. The nurses use clinical guidelines approved by the Department of Health and Hospitals to see if the service is medically necessary.
- If the request cannot be approved by a AmeriHealth Caritas Louisiana nurse, a AmeriHealth Caritas Louisiana doctor will review the request.
- If the request is approved, we will contact your health care provider.
- If the request is not approved, a letter will be sent to you and your health care provider telling you the reason for the decision.
- If you disagree with the decision, you may file a Grievance, Appeal and/or request a Fair Hearing. Please go to Grievances, Appeals and Fair Hearings for more information.
- You may also call Member Services for help in filing a Grievance, Appeal and/or Fair Hearing.
Please talk to your doctor about the services you need and if they will need prior authorization.
As a AmeriHealth Caritas Louisiana member, you are not responsible to pay for medically necessary, covered services received from AmeriHealth Caritas Louisiana network providers.
You may have to pay when:
- A service is provided by a provider who is not in the AmeriHealth Caritas Louisiana network and prior authorization was not given to see this provider (except for emergency services)
- The service provided is not covered by AmeriHealth Caritas Louisiana, your provider told you that it is not covered, and you signed a written agreement to pay for the service before you received it