CurrentAmeriHealthPolicy N/A

Precertification Requirements for Elective Services

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Governs which elective, non-emergency services and items require precertification for AmeriHealth members; affects providers and members subject to the payer's benefit plans.

Policy Summary

PayerAmeriHealth

PolicyPrecertification Requirements for Elective Services

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain precertification for elective, non-emergency services; precertification does not guarantee coverage and plan terms must be checked.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+service categories listed

>10genetic test groups

Namedexternal reviewers

81400-81408non-specific codes

Appliesclass-wide drug precert

Services, Tests, and Drugs Requiring Precertification

Relevant Procedure and Product Codes

Precertification code list (refer to portal)mixed

A published list of medical codes for services requiring precertification is available on the Medical Policy Portal for commercial Medicare Advantage members.

Codes triggering precertification reviewCPTCovered

81400-81408	Non-specific molecular pathology procedure codes
81479	Unlisted molecular pathology procedure
81599	Unlisted new technology
84999	Unlisted chemistry procedure

Gene therapies (product list)mixed

	Casgevy ®
	clemidsogene lanparvovec*
	Elevidys™
	etuvetidigene autotemcel*
	Hemgenix ®
	Itvisma ®
	Kebilidi ®
	Lenmeldy™
	Luxturna™
	Lyfgenia™

1–10 of 19

1/2

Other specialty drug listsmixed

	Cingal ®
	Durolane ®
	Euflexxa™
	Gel-One ®
	Gelsyn-3™
	Hyalgan ®
	GenVisc 850 ®
	Hymovis ®
	Supartz ®
	Synojoynt™

1–10 of 59

1/6

Precertification requirement — genetic test codes

Precertification triggerAny genetic test billed with non-specific CPT procedure codes 81400-81408 or with unlisted codes 81479, 81599, 84999 requires precertification review.

Codes referencedCPT® codes 81400-81408; unlisted codes 81479, 81599, 84999.

ReviewerPrecertification review for these codes is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore).

Benefit variabilityPrecertification review benefit may vary based on the member's employer group decision.

Precertification Actions, Vendor Reviews, and Billing Notes

Note

Precertification requirement and coverage note

Services performed on an elective, non-emergency basis require precertification. Precertification does not guarantee coverage — the member's benefit plan terms and conditions determine coverage and any exclusions. A published list of medical codes for services that require precertification is available on the Medical Policy Portal for commercial and Medicare Advantage members.

Prior Authorization

Third-party precertification (Carelon/AIM)

Certain services require precertification review by Carelon Medical Benefits Management (formerly AIM Specialty Health). Providers should obtain precertification through Carelon where indicated; note that a favorable precertification decision does not guarantee benefits under the member's plan and employer group decisions may affect coverage.

Day rehabilitation programs
Elective (non-emergency) ground, air, and sea ambulance transportation
Services marked with a † in the policy indicate Carelon/AIM precertification

Prior Authorization

Third-party precertification (eviCore/CareCore)

Precertification review for certain therapies and specialty services is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). Providers must obtain precertification from eviCore for the services listed below; as with other vendors, a precertification determination by eviCore does not itself guarantee coverage under the member's benefit plan or employer group decisions.

Hyperbaric oxygen therapy
Proton beam therapy
ANY genetic test billed with non-specific or unlisted procedure codes (see separate item)

Prior Authorization

Third-party precertification (Tango)

Precertification review for home-care services for Pennsylvania Medicare lines of business is provided by Tango, an independent company. Obtain precertification through Tango where required; precertification determinations are subject to the member's benefit plan and any employer group decisions.

Home-care services for PA Medicare lines of business

Prior Authorization

Precertification for non-specific genetic test codes

Any genetic test billed with a non-specific procedure code or an unlisted code requires precertification review. Providers must submit these tests for precertification to eviCore as noted; precertification does not guarantee benefits and coverage is determined by the member's plan and employer group decisions.

Billed with CPT codes 81400 - 81408
Billed with unlisted codes: 81479, 81599, 84999
Precertification review for these non-specific or unlisted genetic test codes is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore)

Definitions and Vendor Notes

Precertification — definition and coverage note

DefinitionPrecertification is a review required before elective, non-emergency services.

ScopeApplies to services performed on an elective, non-emergency basis.

Coverage notePrecertification does not guarantee coverage; plan benefit terms determine coverage and exclusions.

Reference resourceA published list of medical codes for services requiring precertification is available on the Medical Policy Portal for commercial Medicare Advantage members.

Vendor-reviewed services (†)

Marker meaningServices marked with † are reviewed by specified external precertification vendors.

Example vendorCarelon Medical Benefits Management (formerly AIM Specialty Health) performs precertification for some services (marked †).

Employer group impactPrecertification review benefit may vary based on decision by the member's employer group.

Precertification review provided by eviCore

Reviewer identityPrecertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore).

Applicable testseviCore provides review for genetic tests billed with non-specific or unlisted procedure codes as listed in the policy.

Benefit variabilityPrecertification review benefit varies based on the member's employer group decision.

Class-wide precertification requirement

Class-wide ruleAll drugs that can be classified under the given header require precertification, including any unlisted brand or generic names and biosimilars.

New approvalsIncludes new drugs approved by the FDA in that class during the benefit year.

ScopeApplies to every product that fits the listed therapeutic header (e.g., hyaluronate acid products).

Precertification / eviCore (reviewer)

ReviewerPrecertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company.

IndependenceeviCore operates as an independent company performing the review on behalf of the payer.

Benefit variabilityPrecertification review benefit varies based on decision by the member's employer group.

Biosimilar precertification

Biosimilar scopePrecertification requirements apply to all FDA‑approved biosimilars to the reference product.

InclusionBiosimilars are treated the same as their reference products for precertification in the specified drug classes.

Policy notePrecertification applies regardless of brand or biosimilar designation within the class header.

Benefit exclusion for listed specialty drugs

Existence of exclusionsSome commercial groups/members have a benefit exclusion for these drugs.

Implication for providersEven if a drug requires precertification, coverage may be excluded for certain employer groups—verify benefit terms.

Referenced classesExclusions may apply to drugs listed under class headers such as hyaluronate acid products.

Policy Summary

PayerAmeriHealth

PolicyPrecertification Requirements for Elective Services

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain precertification for elective, non-emergency services; precertification does not guarantee coverage and plan terms must be checked.

SourceLink

On This Page

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Precertification Requirements for Elective Services

Customize your policy alerts

Sign up for all AmeriHealth policy alerts

Know when AmeriHealth releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Governs which elective, non-emergency services and items require precertification for AmeriHealth members; affects providers and members subject to the payer's benefit plans.

Relevant Procedure and Product Codes

Precertification code list (refer to portal)mixed

A published list of medical codes for services requiring precertification is available on the Medical Policy Portal for commercial Medicare Advantage members.

Codes triggering precertification reviewCPTCovered

81400-81408	Non-specific molecular pathology procedure codes
81479	Unlisted molecular pathology procedure
81599	Unlisted new technology
84999	Unlisted chemistry procedure

Gene therapies (product list)mixed

	Casgevy ®
	clemidsogene lanparvovec*
	Elevidys™
	etuvetidigene autotemcel*
	Hemgenix ®
	Itvisma ®
	Kebilidi ®
	Lenmeldy™
	Luxturna™
	Lyfgenia™

1–10 of 19

1/2

Other specialty drug listsmixed

	Cingal ®
	Durolane ®
	Euflexxa™
	Gel-One ®
	Gelsyn-3™
	Hyalgan ®
	GenVisc 850 ®
	Hymovis ®
	Supartz ®
	Synojoynt™

1–10 of 59

1/6

Precertification requirement — genetic test codes

Precertification triggerAny genetic test billed with non-specific CPT procedure codes 81400-81408 or with unlisted codes 81479, 81599, 84999 requires precertification review.

Codes referencedCPT® codes 81400-81408; unlisted codes 81479, 81599, 84999.

ReviewerPrecertification review for these codes is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore).

Benefit variabilityPrecertification review benefit may vary based on the member's employer group decision.

Precertification Actions, Vendor Reviews, and Billing Notes

Note

Precertification requirement and coverage note

Prior Authorization

Third-party precertification (Carelon/AIM)

Day rehabilitation programs
Elective (non-emergency) ground, air, and sea ambulance transportation
Services marked with a † in the policy indicate Carelon/AIM precertification

Prior Authorization

Third-party precertification (eviCore/CareCore)

Hyperbaric oxygen therapy
Proton beam therapy
ANY genetic test billed with non-specific or unlisted procedure codes (see separate item)

Prior Authorization

Third-party precertification (Tango)

Home-care services for PA Medicare lines of business

Prior Authorization

Precertification for non-specific genetic test codes

Billed with CPT codes 81400 - 81408
Billed with unlisted codes: 81479, 81599, 84999
Precertification review for these non-specific or unlisted genetic test codes is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore)

Definitions and Vendor Notes

Precertification — definition and coverage note

DefinitionPrecertification is a review required before elective, non-emergency services.

ScopeApplies to services performed on an elective, non-emergency basis.

Coverage notePrecertification does not guarantee coverage; plan benefit terms determine coverage and exclusions.

Reference resourceA published list of medical codes for services requiring precertification is available on the Medical Policy Portal for commercial Medicare Advantage members.

Vendor-reviewed services (†)

Marker meaningServices marked with † are reviewed by specified external precertification vendors.

Example vendorCarelon Medical Benefits Management (formerly AIM Specialty Health) performs precertification for some services (marked †).

Employer group impactPrecertification review benefit may vary based on decision by the member's employer group.

Precertification review provided by eviCore

Reviewer identityPrecertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore).

Applicable testseviCore provides review for genetic tests billed with non-specific or unlisted procedure codes as listed in the policy.

Benefit variabilityPrecertification review benefit varies based on the member's employer group decision.

Class-wide precertification requirement

Class-wide ruleAll drugs that can be classified under the given header require precertification, including any unlisted brand or generic names and biosimilars.

New approvalsIncludes new drugs approved by the FDA in that class during the benefit year.

ScopeApplies to every product that fits the listed therapeutic header (e.g., hyaluronate acid products).

Precertification / eviCore (reviewer)

ReviewerPrecertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company.

IndependenceeviCore operates as an independent company performing the review on behalf of the payer.

Benefit variabilityPrecertification review benefit varies based on decision by the member's employer group.

Biosimilar precertification

Biosimilar scopePrecertification requirements apply to all FDA‑approved biosimilars to the reference product.

InclusionBiosimilars are treated the same as their reference products for precertification in the specified drug classes.

Policy notePrecertification applies regardless of brand or biosimilar designation within the class header.

Benefit exclusion for listed specialty drugs

Existence of exclusionsSome commercial groups/members have a benefit exclusion for these drugs.

Implication for providersEven if a drug requires precertification, coverage may be excluded for certain employer groups—verify benefit terms.

Referenced classesExclusions may apply to drugs listed under class headers such as hyaluronate acid products.