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Attention! An update has been made to this
page.
As an important reminder, certain procedures, services, items, and specialty
drugs require preapproval/precertification from AmeriHealth prior to being
rendered to or performed for our members. Failure to obtain required
preapproval/precertification may result in a reduction in payment or nonpayment
to the provider for the services or drugs not preapproved/precertified by
AmeriHealth.
New denial notification procedure (for AmeriHealth Pennsylvania members only)
AmeriHealth has discontinued sending letters to notify providers of denials
for procedures, services, items, and specialty drugs due to of lack of
preapproval/precertification within the specified time frame.
Instead, denial notifications due to lack of preapproval/precertification
within the specified time frame will be communicated to providers via
telephone. The denial decision is final, and there will be no opportunity to
appeal. Note: This does not apply to denials for medical
necessity.
Resources
For your convenience, we maintain comprehensive preapproval/precertification
lists that outline the procedures, services, items, and specialty drugs that
require preapproval/precertification. These lists are available online for AmeriHealth New Jersey and AmeriHealth
Pennsylvania.
In addition, a supplementary document, Services Requiring
Precertification, is available and includes the CPT® and
HCPCS codes, where applicable, that correlate with the procedures, services,
items, and specialty drugs on the Preapproval/Precertification List. For
your convenience, there is a link to this document included on the
Preapproval/Precertification List.
You can also access Services Requiring Precertification by visiting
our Medical Policy Portal
and selecting Accept and Go to Medical Policy Online. Then select the
Commercial tab from the top of the page. Then select New Jersey
or Pennsylvania under Services Requiring Precertification from the
left-hand menu.
CPT Copyright 2016 American Medical Association. All
rights reserved. CPT® is a registered trademark of the American
Medical Association.
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