amerigroup
Amerigroup

 

*Important note regarding Amerigroup referrals: Effective 11/7/2011, Amerigroup no longer requires referrals to participating specialists. Please refer to the Quick Reference Guide for more details. For precertification inquiries, use the Precertification Tool available on the Amerigroup website.

  • NaviNet (requires log-in)

  • Amerigroup website

    • Clear Claim Connection™

      This tool allows providers to utilize the McKesson ClaimCheck® software to view how a claim may process based on the diagnosis and procedure codes entered. To access this feature, you will need to log-in to Amerigroup by clicking the link above. Once logged-in, the RealTools... menu will appear on the right. Select Claims, then Clear Claim Connection.

 

»»» Back to list: Referral, Precertification, and Preauthorization Requirements by Managed Care Organization «««

 

 

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Referral, Precertification, and Preauthorization Requirements

 

*Important note regarding Amerigroup referrals: Effective 11/7/2011, Amerigroup no longer requires referrals to participating specialists. Please refer to the Quick Reference Guide for more details. For precertification inquiries, use the Precertification Tool available on the Amerigroup website.

Primary Care Medicine/ Pediatrics

 

Referrals to participating specialists are no longer required.

For non-participating providers: Initial referrals may be issued using script with specialist's name, date of service, and number of visits requested. Referrals must be faxed to 1-800-964-3627 prior to appointment. (Note: Referrals may also be issued using Amerigroup standard referral form.) Click here to download form.

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Ancillary Services

 

Service

What’s required?

Who can issue?

How to request.

Second Opinion Required?

Additional Information

Lab

Offices with limited or no office lab services, should refer patients to LabCorp or Quest Diagnostics. All lab services furnished by non-network providers require precertification before performing lab services.

Call 1-800-454-3730 to obtain precertfication.

Radiology, CAT Scan, MRI*, Ultrasound (Non OB Related), Nuclear Medicine

Precertification required for MRA, MRI, CAT, PET, nuclear cardiac scans, video EEG, and any other nuclear radiology procedure.

Not required for routine diagnostic testing.

PCP

or

Specialist

Phone

1-800-454-3730

or

Fax precertification request form to

1-800-964-3627.

Click here to download precertification request form.

 No

MRA, MRI, CAT, PET, and nuclear cardiac scans require precertification via National Imaging Associates (NIA). Call NIA at 1-800-642-7565 to locate a network radiology service provider.

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Specialists

Referrals are no longer required for participating specialists. For non-participating specialists, see information below.

Service

What’s required?

Who can issue?

How to request.

Second Opinion Required?

Additional Information

Orthopedics, Ophthalmology, ENT, Podiatric

*Script/ Referral

 

*Not required for participating specialists.

PCP,

Optometrist,

In-Network Specialist

Fax to 1-800-964-3627 prior to services being rendered.

 

 No

Standing and extended referrals must be authorized by Amerigroup.

Call 1-800-454-3730 to obtain preauthorization.

Cardiology, Dermatology, Endocrinology, Gastroenterology

*Script/ Referral

 

*Not required for participating specialists.

PCP

Fax to 1-800-964-3627 prior to services being rendered.

 No

Standing and extended referrals must be authorized by Amerigroup.

Call 1-800-454-3730 to obtain preauthorization..

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OB/GYN

 

Obstetrics

No precertification required for services performed by participating providers. Notify Amerigroup at first prenatal visit. Two ultrasounds covered for normal pregnancy diagnosis. Notify within 24 hours for emergency obstetric admissions.

No precertification required for sterilization procedures, including tubal ligation.

Termination of Pregnancy- covered by Straight Medicaid/SCHIP/Family Care only.

Gynecology

Self-referral service. No precertification required for testing and procedures. Well-woman exam covered once per year (includes routine lab work, STD screening, Pap smear, and mammogram for women aged 35 and older).

No precertification required for sterilization procedures, including tubal ligation. Sterilization consent form is required for claim submission for primary sterilization.

Sterilization reversal and sterilizations performed by nonparticipating providers are not covered.

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Physical Medicine & Rehab

 

Service

What’s required?

Who can issue?

How to request

Second Opinion Required?

Additional Information

E/M Services

No precertification required.

Outpatient PT, OT, ST are covered by Medicaid FFS.

All other services

Precertification

PCP

Phone

1-800-454-3730

or

Fax precertification request form to

1-800-964-3627.

Click here to download precertification request form.

No

 

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Same Day Surgery

 

Service

What’s required?

Who can issue?

How to request

Second Opinion Required?

Additional Information

Same Day Surgery
Includes Medical Special Procedures and Cath Lab

Precertification

PCP,

Specialist

Phone

1-800-454-3730

or

Fax precertification request form to

1-800-964-3627.

Click here to download precertification request form.

No

Precertification required based on procedure.

Click here to use the Precertification Lookup Tool.

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Plastic Surgery

 

Service

What’s required?

Who can issue?

How to request

Second Opinion Required?

Additional Information

E/M Services,

Oral Maxillofacial E/M Services

No precertification required.

Cosmetic Services

No coverage.

 

All Other Services (including trauma to teeth and TMJ)

Precertification

PCP,

Specialist

Phone

1-800-454-3730

or

Fax precertification request form to

1-800-964-3627.

Click here to download precertification request form.

No

See provider manual for list of plastic, cosmetic, or reconstructive surgery services requiring precertification.

-OR-

Use the Precertification Lookup Tool.

Reduction mammoplasty requires medical director's review. Call 1-800-454-3730.

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Non-Emergent Ambulance (Transport)

 

Lower-mode transportation available to any member requesting transportation to any provider for a medically necessary covered benefit if the location is greater than 30 miles from the member's residence when there is no closer network provider available.

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Participating and Non-Participating

Group Agreement Information

Plan Type

  • Medicaid HMO

NJMS Faculty Group Agreement

  • Yes

The University Hospital Agreement

  • Yes

For detailed contract information call the Managed Care Office at 973-972-4908.

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