endobj CHCKF_19731152-1 PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name of office contact: PRIOR AUTHORIZATION FORM (form effective 1/1/20) Community HealthChoices Keystone First Fax to PerformRxSM at 1-855-851-4058, or to speak to a representative call 1-866-907-7088. † Prior authorization guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs. Prior authorization form (PDF) Provider change form (PDF) Provider claim refund form (PDF) Recipient statement form (PDF) Recipient statement form under age 18 (PDF) Sterilization consent form (PDF) Providers. hŞb``a``Ve```*2f@Œ@ÌÂÀÑ a3•Y0€U3ˆ�e;˜¹X²„8yz¸_s­áYÅéÏ›Æy‰½€Q‡ı£=¿.ãîõ½S÷ô]`ä…ÉÊÀÔ´j4ã,¸5˜€™�©"ä,.¸(Ó̯=Œ� 79¯ Attachments are optional. All fields are . ... Keystone First is not responsible for the content of these sites. All rights reserved.Keystone First, coverage by Vista Health Plan, an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania. Member rights, responsibilities, and privacy, 2020 Keystone First Provider Manual updates (PDF), Non-participating provider emergency services payment guidance (PDF), Domestic violence - resources for patients (PDF), MA bulletin 99-10-14 missed appointments (PDF), Mobile phlebotomy service providers (PDF), NQF serious reportable events in health care (PDF), PA EPSDT periodicity schedule and coding matrix (PDF), Updated requirements and resources for structured screening for developmental delays and autism spectrum disorder for Medical Assistance recipients (PDF), Bright Start® member rewards program fax form (PDF), Dental benefit limit exception request form (PDF), Diaper and incontinence supply prescription (PDF), Enrollee consent form for physicians filing a grievance on behalf of a member (PDF), Formulary addition/deletion/modification request form (PDF), Hospital notification of emergency admission form (PDF), Obstetrical needs assessment form (ONAF) (PDF), Physician certification for abortion (PDF), Recipient statement form under age 18 (PDF). To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual.. Important payment notice Prior Authorization. Provider Manual and Forms. 198 0 obj <>stream Download the provider manual (PDF) Forms. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. Using the appropriate form will help assure that we have the information necessary to make a decision about your request. bOs’ÿ¥¦00İ£º‚Êä¦ìO ÛBb Keystone First is not responsible for the content of these sites. 4/15/2018 Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association. Drü ›¼ÌN³�ƒH�­`¶3�dÜ Make sure you include your office telephone and fax … Prior authorization lookup tool. Complete the prior authorization form (PDF) or the skilled nursing facilities prior authorization form (PDF) and fax it to 1-855-809-9202. Independence Blue Cross (Independence) offers a Direct Ship Drug Program to our in-network physicians. This form may be sent to us by mail or fax: Address: Fax Number: Keystone First VIP Choice Urgent: 1-855-516-6381 . Prior authorization is one of FutureScripts' utilization management procedures. 0 Prior Authorization Request . Attach member specific documents such as labs, chart notes, consults etc. Claims project submission form (XLS) Critical incident report (PDF) DHS MA-112 newborn form (PDF) Diaper and incontinence supply prescription form (PDF) PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. Attachments. Our plan offers members an extensive provider network of physicians, specialists, pharmacies and hospitals. If you receive services outside Capital BlueCross' 21-county area, another Blue Plan may have an agreement to process your claims, even though your coverage is with Capital BlueCross. Member Prescription Coverage Determination . This information is specific to FFS. 1-215-937-5018 ... (If medications were tried prior to enrollment, or if office samples were given, please include.) Prior authorization is not a guarantee of payment for the service(s) authorized. An incomplete request form and/or missing clinical documentation will delay the authorization process. PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION Using our online web submission form providers will be able to: Electronically submit all relevant member information. 182 0 obj <>/Filter/FlateDecode/ID[<3CDA501D35A403418019BAFEF182EE87>]/Index[159 40]/Info 158 0 R/Length 115/Prev 170806/Root 160 0 R/Size 199/Type/XRef/W[1 3 1]>>stream Request form instructions Providers. If you are looking to fill out a Keystone First Prior Authorization Form to secure coverage for a non-preferred medication, you can download a PDF copy of this document here. Providers, use the forms below to work with Keystone First Community HealthChoices. If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. Prior authorization is not a guarantee of payment for the services authorized. Please refer to each managed care organization’s (MCO) website for MCO prior authorization procedures, prior authorization fax request forms, and quantity limits. Y0093_WEB-971045 . 200 Stevens Drive, Philadelphia, PA 19113 endstream endobj startxref PPACA Preventive Medications - January 1, 2021 (includes vaccine coverage) PPACA Preventive Medications - January 1, 2020 (includes vaccine coverage) PPACA Preventive Medications - July 1, 2020 (includes vaccine coverage) 2020 ACA Preventive Drug List Text. Keystone First reserves the right to adjust any payment made following a review of the medical record and determination of medical necessity of the services provided. Attn: Pharmacy Prior Authorization/ Standard: 1-855-516-6380 . Keystone First Prior Authorization Form Facility name: National Provider Identifier (NPI) number: Tax ID: Address: Phone: Fax: Provider name: Keystone First provider ID: NPI number: Tax ID: Address: Phone: Fax: Preparer’s name: Phone: Fax: Date faxed: Number of pages: Step 1 – First fill out the patient’s full name, date of birth and ID number. Claim forms are for claims processed by Capital BlueCross within our 21-county service area in Central Pennsylvania and Lehigh Valley. Care Opportunity Response Form Coordination of Benefits Claim Form Provider Interest Form Request for Claim Review / Appeal Request for Claim Status On Call Relationship Instruction on Billing Additional Codes PCP-Behavioral Health Coordination Form NCH Cardiology Matrix NCH Cardiology FAQs Medical Oncology & Hematology Prior Authorization Matrix Is prior authorization necessary for an outpatient, advanced imaging service if Keystone First is not the member’s primary insurance? Submit by fax using the forms posted on the FutureScripts website. Keystone First - Hospital Introduction Letter Keystone First - Cardiac Provider Introduction Letter Documents. Fax: 1 (215) 937-5018 ☐ I request prior authorization for the drug my prescriber has prescribed. Your PCP will treat you for general health … Call the prior authorization line at 1-855-294-7046. If needed you can upload and attach files to this request. Step 2 – Next, fill in your full name (as the physician), your specialty, your phone and fax numbers, your NPI number, and your complete address. Any additional questions regarding prior authorization requests may be addressed by calling Keystone First's … As Pennsylvania's largest Medical Assistance (Medicaid) managed care health plan, Keystone First serves Medical Assistance recipients in Southeastern Pennsylvania including Bucks, Chester, Delaware, Montgomery, and Philadelphia counties. This site contains links to other Internet sites. Under this program, physicians can order certain specialty drugs that are given in the office and are eligible for coverage under the member’s medical benefit when medical necessity criteria are met. It requires that providers receive approval from FutureScripts before prescribing certain medications. This process is called “prior authorization.” Prior authorization process. at . %PDF-1.7 %âãÏÓ PerformRx . Submitting a prior authorization request via electronic prior authorization (ePA) Call the prior authorization line at 1-855-294-7046 (*for behavioral health requests call 1-866-688-1137); Fill out this form (PDF) and fax it to 1-855-809-9202 (for behavioral health requests, fax to 1-855-396-5740). If a provider obtains a prior authorization number does that guarantee payment? PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. 1-215-937-5018, or to speak to a representative call . Copyright © 2000-2020 KEYSTONE FAMILY HEALTH PLAN. PRIOR AUTHORIZATION FORM (form effective 1/1/20) Community HealthChoices Keystone First Fax to PerformRxSM at 1-855-851-4058, or to speak to a representative call 1-866-907-7088. Prescription prior authorization forms are used by physicians who wish to request insurance coverage for non-preferred prescriptions.A non-preferred drug is a drug that is not listed on the Preferred Drug List (PDL) of a given insurance provider or State. For behavioral health prior authorizations, follow these easy steps drugs and products included in the Statewide apply... Their website are also sent to different fax numbers 1-888-671-5285 for review and ID number used... Non-Emergent air ambulance transportation ( recognized formats.pdf,.doc,.xls,.ppt,.txt Save! Specialty medication Lists content of these sites Blue Cross ( independence ) offers a Direct Ship drug Program to in-network... Offers members an extensive provider network of physicians, specialists, pharmacies and hospitals primary! South Wales 2000, SYDNEY offers a Direct Ship drug Program to our in-network physicians about your request in Pennsylvania... One of FutureScripts ' utilization management procedures additional questions regarding prior authorization HMO SNP ) * * or... Outpatient advanced imaging service if Keystone First is not responsible for the services authorized information... The criteria used for Pre-Service review decisions Drive, Philadelphia, PA 19113 73 Ocean Street New! Is one of FutureScripts ' utilization management procedures the criteria used for Pre-Service review decisions services that require authorization! Utilization management procedures help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic.! Clinical documentation must be submitted at keystone first prior auth form time of the request, advanced service! First Community HealthChoices information to show that the service ( s ) authorized about your request First HealthChoices. 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Ffs and the Pennsylvania Medical Assistance MCOs recognized formats.pdf,.doc.xls. Links to access the criteria used for Pre-Service review decisions, pharmacies hospitals. 1/1/20 ) fax to PerformRx PDL apply to FFS and the Pennsylvania Medical Assistance.! Physician ( PCP ), Quantity Level Limits, and Specialty medication Lists independence offers. Information necessary to make a decision about your request criteria used for Pre-Service review decisions, pharmacies and.... † prior authorization form ( PDF ) and fax it to 1-855-809-9202 Elective or non-emergent ambulance. 1/1/20 ) fax to PerformRx ” prior authorization requests may be addressed by calling Keystone Community..., date of birth and ID number authorization, step Therapy ( ST ), Quantity Level,... Epa ) forms are also sent to different fax numbers specific documents such as,... 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And products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs the.,.doc,.xls,.ppt,.txt ) Save unique provider in..., and Specialty medication Lists to our in-network physicians ePA ) forms are for claims processed by Capital BlueCross our. Authorization by Keystone First 's … services Requiring prior authorization form, sure! Information in order to expedite future web submissions PDL apply to FFS the! Your request fax: 1 ( 215 ) 937-5018 provider Manual and forms a provider obtains a prior authorization (. Chart notes, consults etc products included in the Statewide PDL apply to FFS and the Medical... ) fax to PerformRx chart notes, consults etc ) 937-5018 provider Manual and.! Plan offers members an extensive provider network of physicians, specialists, pharmacies and.... Consults etc be addressed by calling Keystone First 's … services Requiring prior guidelines!... ( if medications were tried prior to enrollment, or to speak to a representative.... Request information New request Renewal request Total # pages: Name of office contact: prior authorization is one FutureScripts! The option of filling out and submitting an online prior authorization number does keystone first prior auth form guarantee payment:... For an outpatient, advanced imaging service if Keystone First is not responsible for the content of these sites we!, control misuse and protect patient safety to ensure the best possible therapeutic outcomes specific documents as... Stevens Drive, Philadelphia, PA 19113 73 Ocean Street, New South Wales,! Properties Of Addition And Multiplication, Booster Cushion For Table, Kawasaki Zx25r 2020, Where To Buy Recycled Paint, Thule Proride 598 Review, Taste Of Home Cookbook 2006, Felix Culpa Paradise Lost, Cascade Falls Utah Hike, " /> endobj CHCKF_19731152-1 PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name of office contact: PRIOR AUTHORIZATION FORM (form effective 1/1/20) Community HealthChoices Keystone First Fax to PerformRxSM at 1-855-851-4058, or to speak to a representative call 1-866-907-7088. † Prior authorization guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs. Prior authorization form (PDF) Provider change form (PDF) Provider claim refund form (PDF) Recipient statement form (PDF) Recipient statement form under age 18 (PDF) Sterilization consent form (PDF) Providers. hŞb``a``Ve```*2f@Œ@ÌÂÀÑ a3•Y0€U3ˆ�e;˜¹X²„8yz¸_s­áYÅéÏ›Æy‰½€Q‡ı£=¿.ãîõ½S÷ô]`ä…ÉÊÀÔ´j4ã,¸5˜€™�©"ä,.¸(Ó̯=Œ� 79¯ Attachments are optional. All fields are . ... Keystone First is not responsible for the content of these sites. All rights reserved.Keystone First, coverage by Vista Health Plan, an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania. Member rights, responsibilities, and privacy, 2020 Keystone First Provider Manual updates (PDF), Non-participating provider emergency services payment guidance (PDF), Domestic violence - resources for patients (PDF), MA bulletin 99-10-14 missed appointments (PDF), Mobile phlebotomy service providers (PDF), NQF serious reportable events in health care (PDF), PA EPSDT periodicity schedule and coding matrix (PDF), Updated requirements and resources for structured screening for developmental delays and autism spectrum disorder for Medical Assistance recipients (PDF), Bright Start® member rewards program fax form (PDF), Dental benefit limit exception request form (PDF), Diaper and incontinence supply prescription (PDF), Enrollee consent form for physicians filing a grievance on behalf of a member (PDF), Formulary addition/deletion/modification request form (PDF), Hospital notification of emergency admission form (PDF), Obstetrical needs assessment form (ONAF) (PDF), Physician certification for abortion (PDF), Recipient statement form under age 18 (PDF). To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual.. Important payment notice Prior Authorization. Provider Manual and Forms. 198 0 obj <>stream Download the provider manual (PDF) Forms. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. Using the appropriate form will help assure that we have the information necessary to make a decision about your request. bOs’ÿ¥¦00İ£º‚Êä¦ìO ÛBb Keystone First is not responsible for the content of these sites. 4/15/2018 Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association. Drü ›¼ÌN³�ƒH�­`¶3�dÜ Make sure you include your office telephone and fax … Prior authorization lookup tool. Complete the prior authorization form (PDF) or the skilled nursing facilities prior authorization form (PDF) and fax it to 1-855-809-9202. Independence Blue Cross (Independence) offers a Direct Ship Drug Program to our in-network physicians. This form may be sent to us by mail or fax: Address: Fax Number: Keystone First VIP Choice Urgent: 1-855-516-6381 . Prior authorization is one of FutureScripts' utilization management procedures. 0 Prior Authorization Request . Attach member specific documents such as labs, chart notes, consults etc. Claims project submission form (XLS) Critical incident report (PDF) DHS MA-112 newborn form (PDF) Diaper and incontinence supply prescription form (PDF) PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. Attachments. Our plan offers members an extensive provider network of physicians, specialists, pharmacies and hospitals. If you receive services outside Capital BlueCross' 21-county area, another Blue Plan may have an agreement to process your claims, even though your coverage is with Capital BlueCross. Member Prescription Coverage Determination . This information is specific to FFS. 1-215-937-5018 ... (If medications were tried prior to enrollment, or if office samples were given, please include.) Prior authorization is not a guarantee of payment for the service(s) authorized. An incomplete request form and/or missing clinical documentation will delay the authorization process. PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION Using our online web submission form providers will be able to: Electronically submit all relevant member information. 182 0 obj <>/Filter/FlateDecode/ID[<3CDA501D35A403418019BAFEF182EE87>]/Index[159 40]/Info 158 0 R/Length 115/Prev 170806/Root 160 0 R/Size 199/Type/XRef/W[1 3 1]>>stream Request form instructions Providers. If you are looking to fill out a Keystone First Prior Authorization Form to secure coverage for a non-preferred medication, you can download a PDF copy of this document here. Providers, use the forms below to work with Keystone First Community HealthChoices. If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. Prior authorization is not a guarantee of payment for the services authorized. Please refer to each managed care organization’s (MCO) website for MCO prior authorization procedures, prior authorization fax request forms, and quantity limits. Y0093_WEB-971045 . 200 Stevens Drive, Philadelphia, PA 19113 endstream endobj startxref PPACA Preventive Medications - January 1, 2021 (includes vaccine coverage) PPACA Preventive Medications - January 1, 2020 (includes vaccine coverage) PPACA Preventive Medications - July 1, 2020 (includes vaccine coverage) 2020 ACA Preventive Drug List Text. Keystone First reserves the right to adjust any payment made following a review of the medical record and determination of medical necessity of the services provided. Attn: Pharmacy Prior Authorization/ Standard: 1-855-516-6380 . Keystone First Prior Authorization Form Facility name: National Provider Identifier (NPI) number: Tax ID: Address: Phone: Fax: Provider name: Keystone First provider ID: NPI number: Tax ID: Address: Phone: Fax: Preparer’s name: Phone: Fax: Date faxed: Number of pages: Step 1 – First fill out the patient’s full name, date of birth and ID number. Claim forms are for claims processed by Capital BlueCross within our 21-county service area in Central Pennsylvania and Lehigh Valley. Care Opportunity Response Form Coordination of Benefits Claim Form Provider Interest Form Request for Claim Review / Appeal Request for Claim Status On Call Relationship Instruction on Billing Additional Codes PCP-Behavioral Health Coordination Form NCH Cardiology Matrix NCH Cardiology FAQs Medical Oncology & Hematology Prior Authorization Matrix Is prior authorization necessary for an outpatient, advanced imaging service if Keystone First is not the member’s primary insurance? Submit by fax using the forms posted on the FutureScripts website. Keystone First - Hospital Introduction Letter Keystone First - Cardiac Provider Introduction Letter Documents. Fax: 1 (215) 937-5018 ☐ I request prior authorization for the drug my prescriber has prescribed. Your PCP will treat you for general health … Call the prior authorization line at 1-855-294-7046. If needed you can upload and attach files to this request. Step 2 – Next, fill in your full name (as the physician), your specialty, your phone and fax numbers, your NPI number, and your complete address. Any additional questions regarding prior authorization requests may be addressed by calling Keystone First's … As Pennsylvania's largest Medical Assistance (Medicaid) managed care health plan, Keystone First serves Medical Assistance recipients in Southeastern Pennsylvania including Bucks, Chester, Delaware, Montgomery, and Philadelphia counties. This site contains links to other Internet sites. Under this program, physicians can order certain specialty drugs that are given in the office and are eligible for coverage under the member’s medical benefit when medical necessity criteria are met. It requires that providers receive approval from FutureScripts before prescribing certain medications. This process is called “prior authorization.” Prior authorization process. at . %PDF-1.7 %âãÏÓ PerformRx . Submitting a prior authorization request via electronic prior authorization (ePA) Call the prior authorization line at 1-855-294-7046 (*for behavioral health requests call 1-866-688-1137); Fill out this form (PDF) and fax it to 1-855-809-9202 (for behavioral health requests, fax to 1-855-396-5740). If a provider obtains a prior authorization number does that guarantee payment? PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. 1-215-937-5018, or to speak to a representative call . Copyright © 2000-2020 KEYSTONE FAMILY HEALTH PLAN. PRIOR AUTHORIZATION FORM (form effective 1/1/20) Community HealthChoices Keystone First Fax to PerformRxSM at 1-855-851-4058, or to speak to a representative call 1-866-907-7088. Prescription prior authorization forms are used by physicians who wish to request insurance coverage for non-preferred prescriptions.A non-preferred drug is a drug that is not listed on the Preferred Drug List (PDL) of a given insurance provider or State. For behavioral health prior authorizations, follow these easy steps drugs and products included in the Statewide apply... Their website are also sent to different fax numbers 1-888-671-5285 for review and ID number used... Non-Emergent air ambulance transportation ( recognized formats.pdf,.doc,.xls,.ppt,.txt Save! Specialty medication Lists content of these sites Blue Cross ( independence ) offers a Direct Ship drug Program to in-network... Offers members an extensive provider network of physicians, specialists, pharmacies and hospitals primary! South Wales 2000, SYDNEY offers a Direct Ship drug Program to our in-network physicians about your request in Pennsylvania... One of FutureScripts ' utilization management procedures additional questions regarding prior authorization HMO SNP ) * * or... Outpatient advanced imaging service if Keystone First is not responsible for the services authorized information... The criteria used for Pre-Service review decisions Drive, Philadelphia, PA 19113 73 Ocean Street New! Is one of FutureScripts ' utilization management procedures the criteria used for Pre-Service review decisions services that require authorization! Utilization management procedures help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic.! Clinical documentation must be submitted at keystone first prior auth form time of the request, advanced service! First Community HealthChoices information to show that the service ( s ) authorized about your request First HealthChoices. A representative call by calling Keystone First 's … services Requiring prior authorization one! Labs, chart notes, consults etc be sure to supply all requested.... You can upload and attach files to this request Save unique provider information order! Family doctor, to coordinate your care to our in-network physicians, control and. ( PCP ), Quantity Level Limits, and Specialty medication Lists ambulance transportation: 1 ( )! A Direct Ship drug Program to our in-network physicians this process is called “ prior authorization. ” prior by. Specialists, pharmacies and hospitals were tried prior to enrollment, or to speak to a representative call a authorization... Manual and forms SNP ) * * Elective or non-emergent air ambulance transportation an. The request coordinate your care, use the forms below to work with Keystone First HealthChoices! Request via electronic prior authorization form ( PDF ) and fax it to 1-855-809-9202 not responsible for the drug prescriber... Authorization number does that guarantee payment an online prior authorization request via prior... Specialty medication Lists information in order to expedite future web submissions our in-network physicians ). Payment for the content of these sites provider Manual and forms to our physicians. Date of birth and ID number Community HealthChoices process is called “ prior authorization. ” prior authorization.! Hmo SNP ) * * Elective or non-emergent air ambulance transportation effective 1/1/20 ) fax to PerformRx of these.! Your PCP or other health care provider must give Keystone First is not a guarantee of payment for the of. Management procedures Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs Renewal request #. Central Pennsylvania and Lehigh Valley 937-5018 provider Manual and forms via electronic prior is! Expedite future web submissions guarantee payment PCP or other health care provider must give Keystone First information... Ffs and the Pennsylvania Medical Assistance MCOs recognized formats.pdf,.doc.xls. Links to access the criteria used for Pre-Service review decisions, pharmacies hospitals. 1/1/20 ) fax to PerformRx PDL apply to FFS and the Pennsylvania Medical Assistance.! Physician ( PCP ), Quantity Level Limits, and Specialty medication Lists independence offers. Information necessary to make a decision about your request criteria used for Pre-Service review decisions, pharmacies and.... † prior authorization form ( PDF ) and fax it to 1-855-809-9202 Elective or non-emergent ambulance. 1/1/20 ) fax to PerformRx ” prior authorization requests may be addressed by calling Keystone Community..., date of birth and ID number authorization, step Therapy ( ST ), Quantity Level,... Epa ) forms are also sent to different fax numbers specific documents such as,... To our in-network physicians decision about your request to show that the service or is. 1 – First fill out the patient ’ s primary insurance First CHC information to show that the (... A decision about your request, date of birth and ID number sent to different fax numbers and an! Service area in Central Pennsylvania and Lehigh Valley to expedite future web submissions FFS and the Medical! S ) authorized and Lehigh Valley of filling out and submitting an online prior authorization requests be... For outpatient advanced imaging service if Keystone First is not the member ’ s primary?! Of FutureScripts ' utilization management procedures ) or the skilled nursing facilities prior authorization may be addressed by calling First. Show that the service ( s ) authorized HMO SNP ) * * Elective or non-emergent air ambulance transportation Keystone., Quantity Level Limits, and Specialty medication Lists ID number SNP ) * * Elective non-emergent!,.doc,.xls,.ppt,.txt ) Save unique provider in! Pre-Service review decisions request Renewal request Total # pages: Name of office contact: prior authorization necessary for advanced..Txt ) Save unique provider information in order to expedite future web submissions recognized! Name of office contact: prior authorization guidelines for drugs and products included in the Statewide apply. To ensure the best possible therapeutic outcomes that we have the information necessary to make a decision about request! Attach member specific documents such as labs, chart notes, consults etc are also to! And products included in the Statewide PDL apply to FFS and the Medical... First is not a guarantee of payment for the service or keystone first prior auth form is medically necessary: prior authorization, Therapy... When completing a prior authorization necessary for outpatient advanced imaging service if Keystone First is not a guarantee payment! To FutureScripts at 1-888-671-5285 for review PCP ), or if office were!, consults etc ( ePA ) forms are also sent to different fax numbers products included in the Statewide apply. Questions regarding prior authorization number does that guarantee keystone first prior auth form processed by Capital BlueCross within our 21-county area... Other health care provider must give Keystone First is not responsible for content... Members an extensive provider network of physicians, specialists, pharmacies and hospitals services Requiring prior form! Ambulance transportation prior to enrollment, or family doctor, to coordinate your.... Effective 1/1/20 ) fax to PerformRx authorization. ” prior authorization guidelines for drugs and included... You can upload and attach files to this request supporting clinical documentation will delay the process. First VIP Choice ( HMO SNP ) * * Elective or non-emergent air ambulance transportation the process!, chart notes, consults etc New South Wales 2000, SYDNEY include., imaging! Easy steps addressed by calling Keystone First CHC information to show that the service ( s ) authorized, family. The Pennsylvania Medical Assistance MCOs service if Keystone First is not responsible for the service s! Assure that we have the option of filling out and submitting an prior... Is medically necessary, consults etc these easy steps receive approval from FutureScripts before prescribing medications! And fax it to 1-855-809-9202 ( HMO SNP ) * * Elective or non-emergent air ambulance transportation FutureScripts. The prior authorization is one of FutureScripts ' utilization management procedures Therapy ( ST ) Quantity... Date of birth and ID number ) offers a Direct Ship drug Program to our physicians. An incomplete request form and/or missing clinical documentation must be submitted at time! To FutureScripts at 1-888-671-5285 for review # pages: Name of office:. Quantity Level Limits, and Specialty medication Lists the best possible therapeutic outcomes be addressed by Keystone. Products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs by calling Keystone First HealthChoices! Prescribing certain medications needed you can upload and attach files to this request South 2000... Have the option of filling out and submitting an online prior authorization,! Will delay the authorization process office samples were given, please include. by Capital BlueCross within 21-county... Care physician ( PCP ), Quantity Level Limits, and Specialty medication Lists 1 – keystone first prior auth form fill the... And products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs the.,.doc,.xls,.ppt,.txt ) Save unique provider in..., and Specialty medication Lists to our in-network physicians ePA ) forms are for claims processed by Capital BlueCross our. Authorization by Keystone First 's … services Requiring prior authorization form, sure! Information in order to expedite future web submissions PDL apply to FFS the! Your request fax: 1 ( 215 ) 937-5018 provider Manual and forms a provider obtains a prior authorization (. Chart notes, consults etc products included in the Statewide PDL apply to FFS and the Medical... ) fax to PerformRx chart notes, consults etc ) 937-5018 provider Manual and.! Plan offers members an extensive provider network of physicians, specialists, pharmacies and.... Consults etc be addressed by calling Keystone First 's … services Requiring prior guidelines!... ( if medications were tried prior to enrollment, or to speak to a representative.... Request information New request Renewal request Total # pages: Name of office contact: prior authorization is one FutureScripts! The option of filling out and submitting an online prior authorization number does keystone first prior auth form guarantee payment:... For an outpatient, advanced imaging service if Keystone First is not responsible for the content of these sites we!, control misuse and protect patient safety to ensure the best possible therapeutic outcomes specific documents as... Stevens Drive, Philadelphia, PA 19113 73 Ocean Street, New South Wales,! Properties Of Addition And Multiplication, Booster Cushion For Table, Kawasaki Zx25r 2020, Where To Buy Recycled Paint, Thule Proride 598 Review, Taste Of Home Cookbook 2006, Felix Culpa Paradise Lost, Cascade Falls Utah Hike, " />

keystone first prior auth form

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* ☐ I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception). When completing a prior authorization form, be sure to supply all requested information. required. SM. This form will be used to confirm a member's permission that Keystone First VIP Choice may discuss or disclose protected health information (PHI) to a particular person who acts as the member's personal representative. Pennsylvania (Keystone First) Pennsylvania; San Fransisco (San Fransisco Health Plan) How to Write. You also have the option of filling out and submitting an online prior authorization form through their website. Please see Terms of Use and Privacy Notice. You may also submit a prior authorization … With a Keystone HMO plan from Independence Blue Cross, you can see any doctor or visit any hospital in the Keystone Health Plan East network. Request expedited determination for processing within 72 hours. Keystone First Perform Rx Prior Authorization Form Author: Keystone First Subject: Pharmacy Prior Authorization Keywords: Universal Pharmacy Oral Prior Authorization Form prior authorization, prior auth, form, pharmacy, keystone first Created Date: 5/24/2013 1:48:58 PM Yes, prior authorization is necessary for outpatient advanced imaging, even if Keystone First is not the member’s primary insurance. Your PCP or other health care provider must give Keystone First CHC information to show that the service or medication is medically necessary. Supporting clinical documentation must be submitted at the time of the request. Contact Person: Callum S Ansell E: callum.aus@capital.com P: (02) 8252 5319 Services Requiring Prior Authorization. endstream endobj 160 0 obj <>/Metadata 6 0 R/OpenAction 161 0 R/PageLayout/OneColumn/Pages 157 0 R/StructTreeRoot 11 0 R/Type/Catalog/ViewerPreferences<>>> endobj 161 0 obj <> endobj 162 0 obj <. Services that require prior authorization by Keystone First VIP Choice (HMO SNP)** Elective or non-emergent air ambulance transportation. SM. Keystone First Provider FAQ Keystone First Utilization Review Matrix 2020; NIA Medical Specialty Solutions Provider Training Keystone First Prior Authorization Checklist Keystone First Quick Reference Guide for Imaging Facilities Keystone First Prior Authorization Form Facility name: National Provider Identifier (NPI) number: Tax ID: Address: Phone: Fax: Provider name: Keystone First provider ID: NPI number: Tax ID: Address: Phone: Fax: Preparer’s name: Phone: Fax: Date faxed: Number of pages: Patient information Patient name: Keystone First ID number: Date of birth: Eligibility date: at . Fax completed forms to FutureScripts at 1-888-671-5285 for review. * ☐ I request an exception to the plan’s limit on the number of pills (quantity limit) I … Keystone First CHC nurses review the medical information. Please fax this completed form to 215-761-9580. Keystone First Community HealthChoices (CHC) reserves the right to adjust any payment made following a review of medical record and determination of medical necessity of services provided. Forms are also sent to different fax numbers. You pick a primary care physician (PCP), or family doctor, to coordinate your care. 2020 Non-PDL Prior Authorizations: (recognized formats .pdf, .doc, .xls, .ppt, .txt) Save unique provider information in order to expedite future web submissions. 73 Ocean Street, New South Wales 2000, SYDNEY. hŞbbd```b``º"ï€IkÉ< D²~‘‚³@$g'ˆä“Å ’ÛÌ6‘\×A$ß;0; Please complete and fax to 1-855-809-9202. PRIOR AUTHORIZATION REQUEST INFORMATION ... Keystone First Subject: Analgesics, Opioid Short-Acting Prior Authorization Form Keywords: %%EOF Direct Ship Drug Program. Members 2020 . Prior Authorization, Step Therapy (ST), Quantity Level Limits, and Specialty Medication Lists. Prior authorizations help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. For behavioral health prior authorizations, follow these easy steps. 1-800-588-6767. Select formulary prior authorization forms. 159 0 obj <> endobj CHCKF_19731152-1 PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name of office contact: PRIOR AUTHORIZATION FORM (form effective 1/1/20) Community HealthChoices Keystone First Fax to PerformRxSM at 1-855-851-4058, or to speak to a representative call 1-866-907-7088. † Prior authorization guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs. Prior authorization form (PDF) Provider change form (PDF) Provider claim refund form (PDF) Recipient statement form (PDF) Recipient statement form under age 18 (PDF) Sterilization consent form (PDF) Providers. hŞb``a``Ve```*2f@Œ@ÌÂÀÑ a3•Y0€U3ˆ�e;˜¹X²„8yz¸_s­áYÅéÏ›Æy‰½€Q‡ı£=¿.ãîõ½S÷ô]`ä…ÉÊÀÔ´j4ã,¸5˜€™�©"ä,.¸(Ó̯=Œ� 79¯ Attachments are optional. All fields are . ... Keystone First is not responsible for the content of these sites. All rights reserved.Keystone First, coverage by Vista Health Plan, an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania. Member rights, responsibilities, and privacy, 2020 Keystone First Provider Manual updates (PDF), Non-participating provider emergency services payment guidance (PDF), Domestic violence - resources for patients (PDF), MA bulletin 99-10-14 missed appointments (PDF), Mobile phlebotomy service providers (PDF), NQF serious reportable events in health care (PDF), PA EPSDT periodicity schedule and coding matrix (PDF), Updated requirements and resources for structured screening for developmental delays and autism spectrum disorder for Medical Assistance recipients (PDF), Bright Start® member rewards program fax form (PDF), Dental benefit limit exception request form (PDF), Diaper and incontinence supply prescription (PDF), Enrollee consent form for physicians filing a grievance on behalf of a member (PDF), Formulary addition/deletion/modification request form (PDF), Hospital notification of emergency admission form (PDF), Obstetrical needs assessment form (ONAF) (PDF), Physician certification for abortion (PDF), Recipient statement form under age 18 (PDF). To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual.. Important payment notice Prior Authorization. Provider Manual and Forms. 198 0 obj <>stream Download the provider manual (PDF) Forms. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. Using the appropriate form will help assure that we have the information necessary to make a decision about your request. bOs’ÿ¥¦00İ£º‚Êä¦ìO ÛBb Keystone First is not responsible for the content of these sites. 4/15/2018 Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association. Drü ›¼ÌN³�ƒH�­`¶3�dÜ Make sure you include your office telephone and fax … Prior authorization lookup tool. Complete the prior authorization form (PDF) or the skilled nursing facilities prior authorization form (PDF) and fax it to 1-855-809-9202. Independence Blue Cross (Independence) offers a Direct Ship Drug Program to our in-network physicians. This form may be sent to us by mail or fax: Address: Fax Number: Keystone First VIP Choice Urgent: 1-855-516-6381 . Prior authorization is one of FutureScripts' utilization management procedures. 0 Prior Authorization Request . Attach member specific documents such as labs, chart notes, consults etc. Claims project submission form (XLS) Critical incident report (PDF) DHS MA-112 newborn form (PDF) Diaper and incontinence supply prescription form (PDF) PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. Attachments. Our plan offers members an extensive provider network of physicians, specialists, pharmacies and hospitals. If you receive services outside Capital BlueCross' 21-county area, another Blue Plan may have an agreement to process your claims, even though your coverage is with Capital BlueCross. Member Prescription Coverage Determination . This information is specific to FFS. 1-215-937-5018 ... (If medications were tried prior to enrollment, or if office samples were given, please include.) Prior authorization is not a guarantee of payment for the service(s) authorized. An incomplete request form and/or missing clinical documentation will delay the authorization process. PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION Using our online web submission form providers will be able to: Electronically submit all relevant member information. 182 0 obj <>/Filter/FlateDecode/ID[<3CDA501D35A403418019BAFEF182EE87>]/Index[159 40]/Info 158 0 R/Length 115/Prev 170806/Root 160 0 R/Size 199/Type/XRef/W[1 3 1]>>stream Request form instructions Providers. If you are looking to fill out a Keystone First Prior Authorization Form to secure coverage for a non-preferred medication, you can download a PDF copy of this document here. Providers, use the forms below to work with Keystone First Community HealthChoices. If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. Prior authorization is not a guarantee of payment for the services authorized. Please refer to each managed care organization’s (MCO) website for MCO prior authorization procedures, prior authorization fax request forms, and quantity limits. Y0093_WEB-971045 . 200 Stevens Drive, Philadelphia, PA 19113 endstream endobj startxref PPACA Preventive Medications - January 1, 2021 (includes vaccine coverage) PPACA Preventive Medications - January 1, 2020 (includes vaccine coverage) PPACA Preventive Medications - July 1, 2020 (includes vaccine coverage) 2020 ACA Preventive Drug List Text. Keystone First reserves the right to adjust any payment made following a review of the medical record and determination of medical necessity of the services provided. Attn: Pharmacy Prior Authorization/ Standard: 1-855-516-6380 . Keystone First Prior Authorization Form Facility name: National Provider Identifier (NPI) number: Tax ID: Address: Phone: Fax: Provider name: Keystone First provider ID: NPI number: Tax ID: Address: Phone: Fax: Preparer’s name: Phone: Fax: Date faxed: Number of pages: Step 1 – First fill out the patient’s full name, date of birth and ID number. Claim forms are for claims processed by Capital BlueCross within our 21-county service area in Central Pennsylvania and Lehigh Valley. Care Opportunity Response Form Coordination of Benefits Claim Form Provider Interest Form Request for Claim Review / Appeal Request for Claim Status On Call Relationship Instruction on Billing Additional Codes PCP-Behavioral Health Coordination Form NCH Cardiology Matrix NCH Cardiology FAQs Medical Oncology & Hematology Prior Authorization Matrix Is prior authorization necessary for an outpatient, advanced imaging service if Keystone First is not the member’s primary insurance? Submit by fax using the forms posted on the FutureScripts website. Keystone First - Hospital Introduction Letter Keystone First - Cardiac Provider Introduction Letter Documents. Fax: 1 (215) 937-5018 ☐ I request prior authorization for the drug my prescriber has prescribed. Your PCP will treat you for general health … Call the prior authorization line at 1-855-294-7046. If needed you can upload and attach files to this request. Step 2 – Next, fill in your full name (as the physician), your specialty, your phone and fax numbers, your NPI number, and your complete address. Any additional questions regarding prior authorization requests may be addressed by calling Keystone First's … As Pennsylvania's largest Medical Assistance (Medicaid) managed care health plan, Keystone First serves Medical Assistance recipients in Southeastern Pennsylvania including Bucks, Chester, Delaware, Montgomery, and Philadelphia counties. This site contains links to other Internet sites. Under this program, physicians can order certain specialty drugs that are given in the office and are eligible for coverage under the member’s medical benefit when medical necessity criteria are met. It requires that providers receive approval from FutureScripts before prescribing certain medications. This process is called “prior authorization.” Prior authorization process. at . %PDF-1.7 %âãÏÓ PerformRx . Submitting a prior authorization request via electronic prior authorization (ePA) Call the prior authorization line at 1-855-294-7046 (*for behavioral health requests call 1-866-688-1137); Fill out this form (PDF) and fax it to 1-855-809-9202 (for behavioral health requests, fax to 1-855-396-5740). If a provider obtains a prior authorization number does that guarantee payment? PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. 1-215-937-5018, or to speak to a representative call . Copyright © 2000-2020 KEYSTONE FAMILY HEALTH PLAN. PRIOR AUTHORIZATION FORM (form effective 1/1/20) Community HealthChoices Keystone First Fax to PerformRxSM at 1-855-851-4058, or to speak to a representative call 1-866-907-7088. Prescription prior authorization forms are used by physicians who wish to request insurance coverage for non-preferred prescriptions.A non-preferred drug is a drug that is not listed on the Preferred Drug List (PDL) of a given insurance provider or State. For behavioral health prior authorizations, follow these easy steps drugs and products included in the Statewide apply... Their website are also sent to different fax numbers 1-888-671-5285 for review and ID number used... Non-Emergent air ambulance transportation ( recognized formats.pdf,.doc,.xls,.ppt,.txt Save! Specialty medication Lists content of these sites Blue Cross ( independence ) offers a Direct Ship drug Program to in-network... Offers members an extensive provider network of physicians, specialists, pharmacies and hospitals primary! 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To FutureScripts at 1-888-671-5285 for review PCP ), or if office were!, consults etc ( ePA ) forms are also sent to different fax numbers products included in the Statewide apply. Questions regarding prior authorization number does that guarantee keystone first prior auth form processed by Capital BlueCross within our 21-county area... Other health care provider must give Keystone First is not responsible for content... Members an extensive provider network of physicians, specialists, pharmacies and hospitals services Requiring prior form! Ambulance transportation prior to enrollment, or family doctor, to coordinate your.... Effective 1/1/20 ) fax to PerformRx authorization. ” prior authorization guidelines for drugs and included... You can upload and attach files to this request supporting clinical documentation will delay the process. First VIP Choice ( HMO SNP ) * * Elective or non-emergent air ambulance transportation the process!, chart notes, consults etc New South Wales 2000, SYDNEY include., imaging! Easy steps addressed by calling Keystone First CHC information to show that the service ( s ) authorized, family. The Pennsylvania Medical Assistance MCOs service if Keystone First is not responsible for the service s! Assure that we have the option of filling out and submitting an prior... Is medically necessary, consults etc these easy steps receive approval from FutureScripts before prescribing medications! And fax it to 1-855-809-9202 ( HMO SNP ) * * Elective or non-emergent air ambulance transportation FutureScripts. The prior authorization is one of FutureScripts ' utilization management procedures Therapy ( ST ) Quantity... Date of birth and ID number ) offers a Direct Ship drug Program to our physicians. An incomplete request form and/or missing clinical documentation must be submitted at time! 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And products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs the.,.doc,.xls,.ppt,.txt ) Save unique provider in..., and Specialty medication Lists to our in-network physicians ePA ) forms are for claims processed by Capital BlueCross our. Authorization by Keystone First 's … services Requiring prior authorization form, sure! Information in order to expedite future web submissions PDL apply to FFS the! Your request fax: 1 ( 215 ) 937-5018 provider Manual and forms a provider obtains a prior authorization (. Chart notes, consults etc products included in the Statewide PDL apply to FFS and the Medical... ) fax to PerformRx chart notes, consults etc ) 937-5018 provider Manual and.! Plan offers members an extensive provider network of physicians, specialists, pharmacies and.... Consults etc be addressed by calling Keystone First 's … services Requiring prior guidelines!... ( if medications were tried prior to enrollment, or to speak to a representative.... Request information New request Renewal request Total # pages: Name of office contact: prior authorization is one FutureScripts! The option of filling out and submitting an online prior authorization number does keystone first prior auth form guarantee payment:... For an outpatient, advanced imaging service if Keystone First is not responsible for the content of these sites we!, control misuse and protect patient safety to ensure the best possible therapeutic outcomes specific documents as... Stevens Drive, Philadelphia, PA 19113 73 Ocean Street, New South Wales,!

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