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AmeriHealth Caritas

AmeriHealth Caritas Prior Authorization

Prior authorization requirements are plan- and service-specific. For AmeriHealth Caritas Next plans, official tools state that elective inpatient services,…

Short answer

Prior authorization requirements are plan- and service-specific. For AmeriHealth Caritas Next plans, official tools state that elective inpatient services, urgent inpatient services, and services from nonparticipating providers always require prior…

AmeriHealth Caritas publishes service-specific prior authorization guidance. Start with the payer resource below, then confirm the member's plan and the requested service before care is scheduled or submitted.

At a glance

  • Prior authorization requirements are plan- and service-specific. For AmeriHealth Caritas Next plans, official tools state that elective inpatient services, urgent inpatient services, and services from nonparticipating providers always require prior authorization. Participating-provider outpatient services can be checked in a plan-specific lookup tool. Online submission is available through the provider portal (NaviNet) and, in North Carolina, through Jiva accessed from NaviNet. For some medical pharmacy buy-and-bill requests, a HCPCS authorization form is used. Out-of-network services generally require authorization except emergency services in the cited Next manual.
  • Requirements vary by state and product; only AmeriHealth Caritas Next examples were located in official source material.
  • The lookup tools are general outpatient tools for participating providers and do not replace the provider manual.
  • Nonparticipating-provider services and out-of-network services have stricter rules in the cited materials.

Where to verify prior authorization requirements

How to submit prior authorization requests

  • Provider portal submission via NaviNet

  • Jiva prior authorization workflow via NaviNet (North Carolina)

  • Fax to the applicable utilization management fax number

  • Telephone to the utilization management number for questions or urgent requests

  • HCPCS authorization form for certain medical pharmacy buy-and-bill requests

  • Submission resource 1

  • Submission resource 2

  • Submission resource 3

Information commonly required

  • CPT or HCPCS code for lookup-based determinations
  • Member and provider details sufficient for the portal request
  • Clinical information supporting medical necessity when requested
  • Information needed for inpatient/admission-related requests
  • For some pharmacy buy-and-bill requests, the HCPCS authorization form

Turnaround notes and caveats

  • Urgent requests that pend may require phone follow-up; the Florida manual states urgent same-day or next-day requests that pend should be called in.
  • Untimely service authorizations may be treated as adverse actions in the Florida Next manual.
  • The cited sources do not provide a single universal turnaround time for all plans/services.
  • Requirements vary by state and product; only AmeriHealth Caritas Next examples were located in official source material.
  • The lookup tools are general outpatient tools for participating providers and do not replace the provider manual.
  • Nonparticipating-provider services and out-of-network services have stricter rules in the cited materials.

Provider resources

Sources

FactValueSourceConfidence
Lookup tool always-required servicesElective inpatient services, urgent inpatient services, and services from a nonparticipating provider always require prior authorization.Officialhigh
Portal submissionOnline prior authorization requests can be submitted in NaviNet.Officialhigh
North Carolina Jiva functionsJiva supports inpatient, outpatient, home care, DME, extension requests, prior authorization, elective admission status verification, admission notifications, and clinical review for auto approval.Officialhigh
Florida manual - authorization channelTo obtain prior authorization or verify requirements, providers may call Utilization Management at 1-833-435-8600.Officialhigh

Last reviewed: March 27, 2026

Sources used: 4 official

Automating prior authorization work

Clark Street Health is testing early-access workflows for requirements checks, status follow-up, document routing, and staff exceptions. Payer rules and clinical decisions still need the controls defined by your practice.

Review the prior authorization workflow