Prior authorization

Some services need to be approved as "medically necessary" by AmeriHealth Caritas Louisiana before your primary care provider (PCP) or other health care provider can help you to get these services. This process is called prior authorization.

 

Services that need prior authorization

 

Medicines:

The Single Preferred Drug List (PDL) is the list of medicines AmeriHealth Caritas Louisiana covers. This list helps your doctor prescribe medicines for you. The list shows which medicines require prior authorization.

See the Louisiana Medicaid Single PDL (Fee for Service and Managed Care Organizations) (PDF).

If a certain medicine is not listed on the drug list, your doctor may ask for it through AmeriHealth Caritas Louisiana's prior authorization (pre-approval) process.

Imaging services:

Some imaging services require prior authorization:

  • CT/CTA
  • CCTA
  • MRI/MRA
  • PET scan
  • MUGA scan
  • Myocardial Perfusion Imaging (MPI)

The doctor who orders the service for you must request the prior authorization.

Services that your doctor must let us know about

  • Maternity obstetrical services (after the first visit) and outpatient care (includes 30-hour observations)
  • All newborn deliveries

If you have Medicare, you may go to Medicare health care providers for services covered by Medicare. Your provider does not need to get the services approved by AmeriHealth Caritas Louisiana.

 
 

Prior authorization process

  1. Your PCP or other health care provider must give AmeriHealth Caritas Louisiana information to show that the service or medication is medically necessary.
  2. AmeriHealth Caritas Louisiana nurses review the medical information. The nurses use clinical guidelines approved by the Louisiana Department of Health to see if the service is medically necessary.
  3. If the request cannot be approved by an AmeriHealth Caritas Louisiana nurse, an AmeriHealth Caritas Louisiana doctor will review the request.
  4. If the request is approved, we will contact your health care provider.
  5. 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.
  6. 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.
  7. 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 an 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)

or

  • 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