Prior Authorizations
Member access to timely, high-quality physical and behavioral health care is the highest priority for AmeriHealth Caritas North Carolina. We recognize that valuable treatment time can be lost for our members when providers are saddled with overly restrictive processes.
As of January 1, 2025, prior authorization and notification requirements for more than 240 physical and behavioral health procedure codes have been eliminated.
See Service-specific guidance for notification requirements, home health and radiology services.
Please use our Prior Authorization Lookup tool for the most up-to-date guidance.
How to submit prior authorizations |
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The fastest way to submit medical prior authorization is electronically via Medical Authorizations in NaviNet. |
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Fax a completed Prior Authorization Request form (PDF) to 1-833-893-2262. |
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8 a.m. to 5 p.m., Monday to Friday |
Authorization decisions are based on the clinical information provided in the request. For medically urgent (less than 72 hours) service requests online, please indicate the procedure is NOT routine/standard.
Reminder: A member does not need authorization to see a primary care physician, go to a local health department or receive services at school-based clinics. ACNC does not require referrals for any services.
Note: If you are unable to locate the service you are seeking or to request services beyond established benefit limits, contact ACNC Utilization Management at 1-833-900-2262.
Service-specific guidance
See the following for prior authorization guidance for specific services. If a service is not listed, please consult the Prior Authorization Lookup Tool. The results of this tool are not a guarantee of coverage or authorization.
Please use our Prior Authorization Lookup Tool for the most up-to-date guidance.
Prior authorization is required for:
- All out-of-network services except emergency services
- Geropsychiatric units in nursing facilities
- Inpatient behavioral health services including hospitalization in an Institution for Mental Disease (IMD)
- Medically managed intensive inpatient services (ASAM Level 4 and 4-WM)
- Research-based behavioral health treatment (RB-BHT) for autism spectrum disorder (ASD)
Please use our Prior Authorization Lookup Tool for the most up-to-date guidance.
No referral or authorization is required for a mental health or substance dependence assessment.
- Ambulatory detoxification
- Behavioral health partial hospitalization
- Behavioral health urgent care (BHUC)
- Child first services
- Diagnostic assessment
- Electroconvulsive therapy (ECT)
- Environmental intervention, interpretation and explanation of results
- Facility-based crisis services for children and adolescents
- Medication-assisted treatment (MAT)
- Mobile crisis management
- Non-hospital medical detoxification
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Outpatient behavioral health psychotherapy
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Outpatient opioid treatment
- Peer-support services
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Professional treatment services in facility-based crisis programs
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Psychiatric and substance use disorder outpatient and medication management services
- Psychological testing
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Substance abuse comprehensive outpatient treatment
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Substance abuse intensive outpatient treatment
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Unlisted psychiatric services
Please use our Prior Authorization Lookup Tool for the most up-to-date guidance. Prior authorization is required for:
- Home health aide services
- Home health speech therapy and skilled nursing
- Home infusion services and injections
- Hospice inpatient services
- Personal care services
- Private duty nursing (extended nursing services)
A member does not need authorization to see a primary care provider, go to a local health department, or receive services at school-based clinics. In addition, a member does not need authorization for the following services or items:
- Emergency room services (in-network and out-of-network)
- 30-hour observations (except for maternity — see Physical health services that require notification)
- Low-level plain films — X-rays, EKG’s
- Family planning services
- Post-stabilization services (in-network and out-of-network)
- Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screening services
- Women’s health care by in-network providers (OB-GYN services)
- Routine vision services
- Dialysis
- Post-operative pain management (must have a surgical procedure on the same date of service)
Providers are asked to notify ACNC within one business day of when the following services are delivered:
- All newborn deliveries, including those that occur in birthing centers
- Maternity obstetrical services (after first visit) and outpatient care (includes observation)
- Continuation of covered services for a new member transitioning to ACNC during the first 90 calendar days of enrollment
- Inpatient admissions following emergency room medical care, emergency short procedure unit services, or an observation stay
How to submit a notification
- The fastest way to submit medical prior authorizations is electronically, via Medical Authorizations in NaviNet.
- Fax a completed Delivery Notification Form (PDF) 1-833-893-2262.
ACNC’s radiology benefits vendor is Evolent. To request prior authorization, contact their provider web portal at any time or by calling 1-800-424-4953, Monday through Friday, 8 a.m. to 8 p.m. ET.
Codes requiring authorization are listed in the Evolent Radiology ACNC Utilization Review Matrix (PDF). Use the Prior Authorization Lookup Tool for immediate guidance.
Emergency room, observation care and inpatient imaging procedures do not require prior authorization.
The ordering physician is responsible for obtaining a prior authorization number for the requested radiology service. Patient symptoms, past clinical history and prior treatment information will be requested by Evolent, and the ordering physician should have this information available at the time of the call.
For additional information on Evolent, to locate Q&As and for Peer-to-Peer Process information, visit RadMD.com.