AmeriHealth 65^® HMO members are required to use their primary care physician?s (PCP) capitated (designated) site for certain services, such as laboratory. This article is a reminder that PCPs must refer AmeriHealth 65 HMO members to their capitated site for these services. In order for a member to receive these services at a location other than the PCP?s capitated site, Clinical Services must provide preapproval based on medical necessity.

To verify what services are capitated for an AmeriHealth 65 HMO member, use the Eligibility and Benefits Inquiry transaction on the NaviNet^® web portal and select the Capitated Site Information link on the Eligibility and Benefits Details screen for that member.

Non-compliance with these guidelines may result in higher costs for the member. For more information about capitated services, please refer to the Provider Manual for Participating Professional Providers.

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