PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION Independence Blue Cross (Independence) offers a Direct Ship Drug Program to our in-network physicians. 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. * ☐ I request an exception to the plan’s limit on the number of pills (quantity limit) I … Y0093_WEB-971045 . 1-800-588-6767. 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. Forms are also sent to different fax numbers. Your PCP will treat you for general health … Please complete and fax to 1-855-809-9202. Providers, use the forms below to work with Keystone First Community HealthChoices. 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. 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. %PDF-1.7 %âãÏÓ 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 ☐ I request prior authorization for the drug my prescriber has prescribed. 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. If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. Using our online web submission form providers will be able to: Electronically submit all relevant member information. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. 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. Supporting clinical documentation must be submitted at the time of the request. 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 . Pennsylvania (Keystone First) Pennsylvania; San Fransisco (San Fransisco Health Plan) How to Write. 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¯ 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. Provider Manual and Forms. 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. SM. This process is called “prior authorization.” Prior authorization process. Attachments are optional. Keystone First CHC nurses review the medical information. Request form instructions Providers. Members 2020 . When completing a prior authorization form, be sure to supply all requested information. Text. Prior Authorization Request . 198 0 obj <>stream 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. An incomplete request form and/or missing clinical documentation will delay the authorization process. 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. † Prior authorization guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs. Important payment notice Contact Person: Callum S Ansell E: callum.aus@capital.com P: (02) 8252 5319 %%EOF Prior Authorization, Step Therapy (ST), Quantity Level Limits, and Specialty Medication Lists. (recognized formats .pdf, .doc, .xls, .ppt, .txt) Save unique provider information in order to expedite future web submissions. Copyright © 2000-2020 KEYSTONE FAMILY HEALTH PLAN. Call the prior authorization line at 1-855-294-7046. at . It requires that providers receive approval from FutureScripts before prescribing certain medications. Prior authorization lookup tool. * ☐ I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception). 73 Ocean Street, New South Wales 2000, SYDNEY. You also have the option of filling out and submitting an online prior authorization form through their website. Yes, prior authorization is necessary for outpatient advanced imaging, even if Keystone First is not the member’s primary insurance. Attachments. Is prior authorization necessary for an outpatient, advanced imaging service if Keystone First is not the member’s primary insurance? Please refer to each managed care organization’s (MCO) website for MCO prior authorization procedures, prior authorization fax request forms, and quantity limits. Please fax this completed form to 215-761-9580. Claim forms are for claims processed by Capital BlueCross within our 21-county service area in Central Pennsylvania and Lehigh Valley. 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 All fields are . PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. 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. This information is specific to FFS. This form may be sent to us by mail or fax: Address: Fax Number: Keystone First VIP Choice Urgent: 1-855-516-6381 . at . Any additional questions regarding prior authorization requests may be addressed by calling Keystone First's … Attach member specific documents such as labs, chart notes, consults etc. Your PCP or other health care provider must give Keystone First CHC information to show that the service or medication is medically necessary. Services Requiring Prior Authorization. For behavioral health prior authorizations, follow these easy steps. Please see Terms of Use and Privacy Notice. Prior authorization is not a guarantee of payment for the service(s) authorized. Our plan offers members an extensive provider network of physicians, specialists, pharmacies and hospitals. Request expedited determination for processing within 72 hours. 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 You pick a primary care physician (PCP), or family doctor, to coordinate your care. Select formulary prior authorization forms. Claims project submission form (XLS) Critical incident report (PDF) DHS MA-112 newborn form (PDF) Diaper and incontinence supply prescription form (PDF) Download the provider manual (PDF) Forms. endstream endobj startxref hŞbbd```b``º"ï€IkÉ< D²~‘‚³@$g'ˆä“Å ’ÛÌ6‘\×A$ß;0; Prior authorization is not a guarantee of payment for the services authorized. 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). bOs’ÿ¥¦00İ£º‚Êä¦ìO ÛBb Submitting a prior authorization request via electronic prior authorization (ePA) 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 2020 Non-PDL Prior Authorizations: Submit by fax using the forms posted on the FutureScripts website. 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. Prior authorizations help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. required. PRIOR AUTHORIZATION REQUEST INFORMATION ... Keystone First Subject: Analgesics, Opioid Short-Acting Prior Authorization Form Keywords: If needed you can upload and attach files to this request. 159 0 obj <> endobj 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: Complete the prior authorization form (PDF) or the skilled nursing facilities prior authorization form (PDF) and fax it to 1-855-809-9202. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual.. Direct Ship Drug Program. PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. 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: 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). 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 Services that require prior authorization by Keystone First VIP Choice (HMO SNP)** Elective or non-emergent air ambulance transportation. ... Keystone First is not responsible for the content of these sites. Keystone First is not responsible for the content of these sites. Fax completed forms to FutureScripts at 1-888-671-5285 for review. Prior authorization is one of FutureScripts' utilization management procedures. Drü ›¼ÌN³�ƒH�­`¶3�dÜ Member Prescription Coverage Determination . 1-215-937-5018 ... (If medications were tried prior to enrollment, or if office samples were given, please include.) Step 1 – First fill out the patient’s full name, date of birth and ID number. Fax: 1 (215) 937-5018 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 <. CHCKF_19731152-1 PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name of office contact: 1-215-937-5018, or to speak to a representative call . 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. 0 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. 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