PLUTO | Providers – Amerigroup
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Provider Notice:

Providers must check state benefits to ensure the request is for a covered benefit. In some cases, state Medicaid contracts or regulatory guidance may supersede both McKesson InterQual Level of Care and Amerigroup medical policy criteria.

Determinations of medical necessity are made on a case-by-case basis. If the request does not meet established criteria guidelines, it will be referred to a licensed physician with the appropriate clinical expertise for review.

Precertification/ Notification Requirements

Participating providers

  • Behavioral Health

  • Fax all requests for services that require precertification to:
    Inpatient 1-877-434-7578
    Outpatient1-800-505-1193

  • The following markets may fax Behavioral Health Outpatient Requests to the specified fax line below to meet turnaround time (TAT) requirements: Iowa, Louisiana and Texas.
    Outpatient 1-866-877-5229

  • Services billed with the following revenue codes ALWAYS require precertification:

  • 0240–0249 — All-inclusive ancillary psychiatric
  • 0901, 0905–0907, 0913, 0917 — Behavioral health treatment services
  • 0944–0945 — Other therapeutic services
  • 0961 — Psychiatric professional fees
  • Pharmacy

    Check our preferred drug list by product and state

  • Services billed with the following revenue codes ALWAYS require precertification:

  • 0632 — Pharmacy multiple sources
  • The following ALWAYS require precertification:

    • Elective services provided by or arranged at nonparticipating facilities

    All services billed with the following revenue codes:

    • 0023 — Home health prospective payment system
    • 0570–0572, 0579 — Home health aide
    • 0944–0945 — Other therapeutic services
    • 3101–3109 — Adult day and foster care

Florida

Medicare

Precertification is not required for physician E&M services for members of the Medicare Advantage Classic plan.

Long-Term Services and Supports

Providers needing an authorization should call 1-877-440-3738.

Georgia

Medicare

Precertification is not required for physician E&M services for members of the Medicare Advantage Classic plan.

Kansas

Long-Term Services and Supports

All services require precertification by fax to 1-855-225-9937.

Louisiana

There are no additional products or services with special instructions at this time.

Maryland

There are no additional products or services with special instructions at this time.

New Jersey

Medicare

Precertification is not required for physician E&M services for members of the Medicare Advantage Balance plan.

Long-Term Services and Supports

All services require precertification.

  • Personal Care Assistants: Call 732-452-6050 and select option 1 or fax requests to 1-888-240-4716
  • Adult Medical Day Care: Fax all requests to 1-888-240-4717

New York

Medicare

Precertification is not required for physician E&M services for members of Medicare Advantage Balance and Classic Choice plans.

Long-Term Services and Supports

All services require precertification. Fax requests to 1-866-574-6721 or call 212-563-5570, ext. 66713.

New Mexico

Medicare

Precertification is not required for physician E&M services for members of the Medicare Advantage Classic plan.

Long-Term Services and Supports

All services require precertification by fax to 1-866-920-8356.

Nevada

There are no additional products or services with special instructions at this time.

Ohio

There are no additional products or services with special instructions at this time.

Tennessee

Medicare

Precertification is not required for physician E&M services for members of the Medicare Advantage Classic plan.

Long-Term Services and Supports

All services require precertification by calling 1-866-840-4991.

Texas

Medicare

Precertification is not required for physician E&M services for members of the Medicare Advantage Classic plan.

Long-Term Services and Supports

All services require precertification. Follow instructions by service area:

  • Austin: Call 512-382-4970 and select option 3 or fax requests to 1-877-744-2334
  • Dallas: Fax requests to 1-888-562-5160
  • El Paso: Fax requests to 1-888-822-5790
  • Lubbock: Fax requests to 1-888-822-5761
  • San Antonio: Call 210-737-5700 and select option 3 or fax requests to 1-877-820-9014

Virgina

There are no additional products or services with special instructions at this time.

  • Search all other services requiring precertification

This tool:

  • Is for outpatient services — inpatient services always require precertification
  • Does not show benefits coverage — refer to our state-specific provider manuals for coverage/limitations

Click select to view code requirements

No Procedure Found.

To refine your search, consider the following:

  • Enter a valid 5-digit code for best results
  • If you are searching by code description, limit your search to a single term for more matches
  • The code you are searching for may be invalid or expired. Such procedures are not available for authorization and will be denied.
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