AmeriHealth Caritas Florida Prior Authorization

AmeriHealth Caritas Florida prior authorization rules are often service-specific rather than universal, so the safest workflow is to confirm the requirement in the payer's provider resources before scheduling or submitting care. The notes below summarize the most actionable provider-side guidance captured in the research set for this payer.

At a glance

• Prior authorization is required for certain services and is service-specific. AmeriHealth Caritas Florida directs providers to use its prior authorization lookup tool and provider manual for the current list. Electronic submission through NaviNet is the preferred method; fax and phone options are also available. Behavioral health services have separate guidance, and at least some outpatient therapy services vary by age and visit type.
• Authorization requirements vary by service, code, provider participation status, and line of business.
• The lookup tool states inpatient services, services with a non-participating provider, and codes not listed on the Florida Medicaid fee schedule always require prior authorization.
• The lookup tool notes that prior authorization requirements also apply to secondary coverage.
• For some services, the provider manual notes that if prior authorization is not granted, associated claims will not be paid.

Where to verify prior authorization requirements

• Verification resource 1
• Verification resource 2
• Verification resource 3
• Verification resource 4

How to submit prior authorization requests

• NaviNet secure provider portal (preferred)

• Fax

• Telephone/Utilization Management phone line

• Submission resource 1

• Submission resource 2

Information commonly required

• Clinical information supporting medical necessity
• Completed authorization request form when submitting by fax
• Member and service details sufficient to identify the requested service
• Supplemental documentation when needed
• For behavioral health, use the behavioral health fax form or call UM

Turnaround notes and caveats

• Behavioral health: standard requests are decided within 7 days and expedited requests within 2 days.
• The general prior authorization page states decisions are made based on the clinical information provided, but no single universal turnaround standard was found for all services.
• Electronic authorization tools may provide auto-approvals in some circumstances.
• Authorization requirements vary by service, code, provider participation status, and line of business.
• The lookup tool states inpatient services, services with a non-participating provider, and codes not listed on the Florida Medicaid fee schedule always require prior authorization.
• The lookup tool notes that prior authorization requirements also apply to secondary coverage.
• For some services, the provider manual notes that if prior authorization is not granted, associated claims will not be paid.

Provider resources

• Providers homepage (official)
• Prior Authorization (official)
• Prior Authorization Lookup Tool (official)
• Claims Submission Process (official)
• Claims Submission Protocols (official)
• Provider Manual (PDF) (official)
• Behavioral Health Prior Authorization Requirements (official)
• Pharmacy Prior Authorization (official)

Sources