Specialists, Prior Authorizations, and Referrals
A specialist is a doctor who has extra training and is an expert on certain health conditions or parts of the body. Your primary care provider (PCP) will know when you need to see a specialist and advise you on what type of specialist you need.
If you have chronic back pain, your PCP might send you to an orthopedist. For heart issues, you might see a cardiologist.
Although referrals are not required, we recommend you contact your PCP before a potential specialist visit to make sure your PCP can better support care coordination for you and your family. Look up your PCP information before your next specialist visit.
Services that require prior authorization:
- All inpatient hospital admissions (including medical, surgical and rehabilitation)
- All out-of-network services (except emergency services)
- Cardiac services
- Elective or non-emergent air ambulance transportation
- Elective transfers (for inpatient and/or outpatient services between acute care facilities)
- Enteral feedings (including related durable medical equipment [DME])
- Home-based services
- Home health care (after 12 visits for therapies and 6 visits for skilled nurse visits)
- Home infusions and injections ($250 and over) provided in an outpatient setting; not required for outpatient hospital setting
- Inpatient medical detoxification
- Inpatient services
- Long-term care (initial placement if still enrolled with the plan)
- Obstetrical admissions and newborn deliveries (exceeding 48 hours after vaginal delivery and 96 hours after cesarean section)
- Private duty nursing and extended home health services (when covered)
- Speech therapy, occupational therapy and physical therapy (after 12 visits for each modality)
- Therapy and related services
Services that do not require prior authorization:
- Diagnosis and treatment of sexually transmitted diseases (STDs) and other communicable diseases, such as tuberculosis and HIV, rendered by the DC Health Department
- Imaging procedures related to emergency room services, observation care, and inpatient care
- Immunizations by the DC Health Department and participating PCPs
- OB/GYN services for 1 annual visit and the medically necessary follow-up care for a condition detected at that visit (the enrollee must use a plan provider for these services)
- Podiatry and some dermatology services (the enrollee must see a plan provider for these services)
- Routine and preventive women's health care services provided by a specialist
Services that require notification:
- Maternity obstetrical services (after the 1st visit) and outpatient care (includes 30-hour observations). Prenatal care providers are expected to complete the D.C. Collaborative perinatal risk screening tool (PDF) to assess risk for each expectant mother. The completed screening tool must be submitted to AmeriHealth Caritas District of Columbia via fax at 1-888-603-5526 as part of the authorization for obstetric services.
- Normal newborn deliveries
Prior authorization process:
- Your PCP or other health care provider must give AmeriHealth Caritas DC information to show that the service or medication is medically necessary
- AmeriHealth Caritas DC nurses or pharmacists review the information. They use clinical guidelines approved by the Department of Human Services to see if the service or medicine is medically necessary.
- If the request cannot be approved by an AmeriHealth Caritas DC nurse or pharmacist, an AmeriHealth Caritas DC doctor will review the request
- If the request is approved, we will let you and your health care provider know it was approved
- 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
- If you disagree with the decision, you may file a complaint or grievance and/or request a fair hearing
- You may also call Enrollee Services for help in filing a complaint or grievance, or requesting a fair hearing