Prior Authorizations and Notifications

Services requiring prior authorizations are subject to change.

A member does not need prior authorization for emergency services or to see a primary care physician. AmeriHealth Caritas Next does not require referrals for any service.

Ways to avoid common errors in electronic prior authorization submissions. Coming Fall 2026.

Physical health and behavioral health prior authorization or notification

Prior Authorization Lookup Tool

Use our Prior Authorization Lookup Tool (coming Fall 2026) to find out if a service requires prior authorization.

Submit a prior authorization request or notification for physical health or behavioral health services:

Online

For online prior authorization, providers can use the Medical Authorizations feature inside our secure provider portal (NaviNet). Coming Fall 2026.

In addition to submitting and inquiring on existing authorizations, you will also be able to:

  • Verify if no authorization is required.
  • Receive auto approvals, in some circumstances.
  • Submit amended authorization.
  • Attach supplemental documentation.
  • Sign up for in-app status-change notifications directly from the health plan.
  • Access a multi-payer authorization log.
  • Submit inpatient concurrent reviews online if you have Health Information Exchange (HIE) capabilities. (Fax is no longer required.)
  • Review inpatient admission notifications and provide supporting clinical documentation.

Video tutorials and step-by-step instructions will be available via the NaviNet Plan Central page and the NantHealth Help Center.

AmeriHealth Caritas Next will offer training on the NaviNet Medical Authorizations system. Contact your Provider Network Management Account Executive for available training dates and times.

By fax

Physical Health Prior Authorization (PDF)  and  Behavioral Health Prior Authorization (PDF)  are available in the forms section of the website.

  • Fax the Physical Health Prior Authorization form. Fax number coming Fall 2026.
  • Fax the Behavioral Health Prior Authorization form. Fax number coming Fall 2026.
  • Fax the Physical Health Prior Authorization form to 1-844-796-1177 for organ transplant initial evaluation notification and for transplant procedures.
By phone

Call our Utilization Management (UM) department (phone number coming Fall 2026) for Physical and Behavioral Health from 8 a.m. to 5 p.m. ET, Monday to Friday.

Call our UM Transplant Team at 1-833-983-7229  from 8 a.m. to 5 p.m. ET, Monday to Friday.

After hours, weekends, and holidays

After business hours, on weekends, and on holidays health care providers, practitioners, and members may contact the UM department through Member Services. Phone number coming Fall 2026.

For organ transplants, contact the UM Transplant Team at 1-833-983-7229. Messages will be monitored seven days a week.

The UM department maintains a UM Reviewer and a Medical Director after business hours, on weekends, and on holidays observed by AmeriHealth Caritas Family of Companies business operations for urgent medical necessity determinations.

A toll-free fax line is available to receive inbound communication 24 hours a day, seven days a week. Communications received after normal business hours are returned on the next business day, and communications received after midnight on Monday to Friday are responded to on the same business day.

Evolent (formerly National Imaging Associates) ― diagnostic imaging services

AmeriHealth Caritas Next has an agreement with Evolent, formerly National Imaging Associates, Inc. (NIA), to manage diagnostic imaging services such as MRI/CT/PET.

The program will require prior authorization from Evolent for nonemergent outpatient:

  • CT/CTA
  • CCTA
  • MRI/MRA
  • PET scan
  • MUGA scan
  • Myocardial perfusion imaging (MPI)

The physician ordering the procedures noted above is responsible for obtaining prior authorization. The rendering facility must ensure that prior authorization was obtained.

We recommend that you develop a process to ensure that the appropriate authorization number(s) has been obtained. Payment to the ordering physician and rendering facility will be denied for procedures performed without necessary authorization.

Providers can request prior authorization via  Evolent's RadMD tool  or by calling Evolent. Phone number coming Fall 2026.

Pharmacy prior authorization

Use the following information to help you with pharmacy prior authorizations:

To submit electronically, please submit an electronic prior authorization (ePA) through your electronic health record (EHR) tool software, or you can submit through either of the following online portals:

By phone

  • Call PerformRxSM Clinical Prior Authorization (phone number coming Fall 2026) from 8 a.m. to 6 p.m. ET, Monday to Friday.

By fax

Both of these forms are available in the Forms section (coming Fall 2026) of the website. The completed forms should be faxed. Fax number coming Fall 2026.

For pharmacy prior authorizations after business hours, weekends, and holidays, please call the 24/7 PerformRx General Assistance number. Phone number coming Fall 2026.