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. * ☐ I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception). This information is specific to FFS. Claims project submission form (XLS) Critical incident report (PDF) DHS MA-112 newborn form (PDF) Diaper and incontinence supply prescription form (PDF) 1-215-937-5018 ... (If medications were tried prior to enrollment, or if office samples were given, please include.) An incomplete request form and/or missing clinical documentation will delay the authorization process. Our plan offers members an extensive provider network of physicians, specialists, pharmacies and hospitals. Attachments. You also have the option of filling out and submitting an online prior authorization form through their website. 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. %PDF-1.7
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To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual.. Complete the prior authorization form (PDF) or the skilled nursing facilities prior authorization form (PDF) and fax it to 1-855-809-9202. Prior authorization lookup tool. Forms are also sent to different fax numbers. 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). ☐ I request prior authorization for the drug my prescriber has prescribed. 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. 73 Ocean Street, New South Wales 2000, SYDNEY. * ☐ I request an exception to the plan’s limit on the number of pills (quantity limit) I … If needed you can upload and attach files to this request. Your PCP will treat you for general health … This process is called “prior authorization.” Prior authorization process. If a provider obtains a prior authorization number does that guarantee payment? Claim forms are for claims processed by Capital BlueCross within our 21-county service area in Central Pennsylvania and Lehigh Valley. Text. When completing a prior authorization form, be sure to supply all requested information. 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 Attn: Pharmacy Prior Authorization/ Standard: 1-855-516-6380 . Any additional questions regarding prior authorization requests may be addressed by calling Keystone First's … Request expedited determination for processing within 72 hours. Independence Blue Cross (Independence) offers a Direct Ship Drug Program to our in-network physicians. Direct Ship Drug Program. 200 Stevens Drive, Philadelphia, PA 19113 Providers, use the forms below to work with Keystone First Community HealthChoices. Prior authorization is one of FutureScripts' utilization management procedures. 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. 1-800-588-6767. Please see Terms of Use and Privacy Notice. Download the provider manual (PDF) Forms. All fields are . Please fax this completed form to 215-761-9580. Yes, prior authorization is necessary for outpatient advanced imaging, even if Keystone First is not the member’s primary insurance. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. 1-215-937-5018, or to speak to a representative call . endstream
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<. (recognized formats .pdf, .doc, .xls, .ppt, .txt) Save unique provider information in order to expedite future web submissions. Members 2020 . This form may be sent to us by mail or fax: Address: Fax Number: Keystone First VIP Choice Urgent: 1-855-516-6381 . hŞbbd```b``º"ï€IkÉ< D²~‘‚³@$g'ˆä“Å ’ÛÌ6‘\×A$ß;0; 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. Contact Person: Callum S Ansell E: callum.aus@capital.com P: (02) 8252 5319 %%EOF
For behavioral health prior authorizations, follow these easy steps. Request form instructions Providers. Keystone First - Hospital Introduction Letter Keystone First - Cardiac Provider Introduction Letter Documents. PRIOR AUTHORIZATION REQUEST INFORMATION ... Keystone First Subject: Analgesics, Opioid Short-Acting Prior Authorization Form Keywords: 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. Is prior authorization necessary for an outpatient, advanced imaging service if Keystone First is not the member’s primary insurance? You may also submit a prior authorization … 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. at . Y0093_WEB-971045 . 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. Provider Manual and Forms. It requires that providers receive approval from FutureScripts before prescribing certain medications. 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 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 guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs. Services Requiring Prior Authorization. You pick a primary care physician (PCP), or family doctor, to coordinate your care. 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. 198 0 obj
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Copyright © 2000-2020 KEYSTONE FAMILY HEALTH PLAN. Submit by fax using the forms posted on the FutureScripts website. Prior Authorization Request . bOs’ÿ¥¦00İ£º‚Êä¦ìO ÛBb
Fax: 1 (215) 937-5018 PerformRx . Make sure you include your office telephone and fax … Submitting a prior authorization request via electronic prior authorization (ePA) Services that require prior authorization by Keystone First VIP Choice (HMO SNP)** Elective or non-emergent air ambulance transportation. PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION Drü ›¼ÌN³�ƒH�`¶3�dÜ This site contains links to other Internet sites. 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 Keystone First is not responsible for the content of these sites. Keystone First CHC nurses review the medical information. required. Prior authorizations help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. 182 0 obj
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... Keystone First is not responsible for the content of these sites. Your PCP or other health care provider must give Keystone First CHC information to show that the service or medication is medically necessary. Prior authorization is not a guarantee of payment for the services authorized. 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. Prior Authorization, Step Therapy (ST), Quantity Level Limits, and Specialty Medication Lists. Select formulary prior authorization forms.
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. 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 Important payment notice Member Prescription Coverage Determination . Supporting clinical documentation must be submitted at the time of the request. 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: 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. endstream
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Please refer to each managed care organization’s (MCO) website for MCO prior authorization procedures, prior authorization fax request forms, and quantity limits. at . 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. 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¯
Prior authorization is not a guarantee of payment for the service(s) authorized. 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. Fax completed forms to FutureScripts at 1-888-671-5285 for review. 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). Please complete and fax to 1-855-809-9202. Attach member specific documents such as labs, chart notes, consults etc. 2020 Non-PDL Prior Authorizations: Pennsylvania (Keystone First) Pennsylvania; San Fransisco (San Fransisco Health Plan) How to Write. PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. SM. 0
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. Attachments are optional. Using our online web submission form providers will be able to: Electronically submit all relevant member information. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. SM. 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. Prior Authorization. 159 0 obj
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