22 23 H3952 Y0041_H3952_KS_20_76771 Accepted 09/02/2019 2020 Summary of Benefits Effective January 1, 2020 through December 31, 2020 • Keystone 65 Basic Rx HMO • Keystone 65 Focus Rx HMO-POS • Keystone 65 Information contained … We’ve provided the following resources to help you understand Anthem’s prior authorization process and obtain authorization for your patients when it’s required. Keystone Health Plan Central members can also enjoy new programs, such as diabetes education, surgery education, and pregnancy and newborn education. To view prior authorization lists for self-funded groups, please visit Plan Central and click on "Related Documents" after logging in. Prior Authorization Health insurance can be complicated—especially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). that is important for the review (e.g., chart notes or lab data, to support the prior authorization or step-therapy exception request [CA ONLY]). FIND YOUR FUTURE MARKET RESEARCH AND INSIGHTS Global Dev hires own own research analyst for market information. Call the prior authorization line at 1-855-294-7046. Prior Authorizations —Time Frames • Keystone First VIP Choice has up to fourteen (14) calendar days to complete a standard request for prior authorization and notify the provider of the organization determination. Fax prior authorization request to the appropriate fax number or toll-free at 1-866-214-2024. Prior Authorization Form Phone: 1-800-521-6622 • Fax: 1-855-332-0115 Contact name: Phone number: Fax number: Participant information Participant name: Participant ID number: Date of birth: Participant’s phone number: An incomplete request form … Keystone First Quick Reference Guide (QRG) for Imaging Providers Effective July 1, 2014 Procedures requiring prior authorization under Keystone First:* CT/CTA. This information is not a complete description of benefits. Dose per fraction. 4-13-18 Oncology Prior Authorization CHCKF_18336058 Please print — accuracy is important. Keystone First Prior Authorization Form Facility name: National Provider Identifier (NPI) number: Tax ID: Address: Phone: Fax: Provider name: Keystone First provider ID: NPI Prior authorization requirement effective June1, 2018. For behavioral health prior authorizations, . AmeriHealth Caritas Pennsylvania’s radiology benefits vendor, National Imaging Associates, Inc. (NIA), provides utilization management review and authorization for non-emergent, advanced, outpatient imaging procedures The rendering facility or provider must verify that prior authorization was obtained prior to rendering the service. Synagis Prior Authorization Form - Pharmacy - Keystone First Author Keystone First Subject Synagis Prior Authorization Form Keywords Synagis Prior Authorization Form Created Date … Prior authorization For members who have prescription drug coverage through Independence Blue Cross (Independence), prior authorization is required for certain prescribed formulary drugs in order for such drugs to be covered. If a provider obtains a prior that guarantee If you are new to electronic prior authorizations (ePA), here are a Pennsylvania (Keystone First) Pennsylvania San Fransisco (San Fransisco Health Plan) How to Write Step 1 – First fill out the patient’s full name, date of birth and ID number. Medical Prior Authorization Request All fields are required. . You also have the option of filling out and submitting an online prior authorization form through their website. The number of fractions requested. Member coverage documents and health plans may require prior authorization for some non-chemotherapy services. Prior Authorization List for Services & Equipment eviCore Provider’s Hub for High Tech Radiology, Radiation Oncology, Medical Oncology, and Molecular Genomic Laboratory Services (Click "Quick Reference Tool" and follow the instructions below) Directions To Albany New York YOUR UNIVERSAL Pennsylvania Medicaid Prior Authorization Form In the State of Pennsylvania, Medicaid coverage for non-preferred drugs is obtained by submitting a Pennsylvania Medicaid prior authorization form . We are not a stock marketing company. Supporting clinical documentation must be submitted at the time of the request. Call 1-800-450-1166 (TTY/TDD 711), 8 a.m. to 8 p.m., seven days a week for more information. PRIOR AUTHORIZATION GUIDELINES BY CATEGORY PH 602.778.1800 (provider menu = option 5) FAX 602.778.1838 Please verify eligibility and benefits prior to rendering services for all members. This information is not a complete description of benefits. Enrollment in Keystone First VIP Choice depends on contract renewal. Prior Authorization Request Form Phone: 800-366-7304 Overview Please complete this form t o request prior a uthorization. Prior authorization can be requested starting August 15, via phone 206-486-3946 or 844-245-6519, fax (206-788-8673) or TurningPoint’s Web portal found at www.myturningpoint-healthcare.com. Founded in 1985, Keystone Health has been in operation for over 30 years. If you have questions, contact the Customer Service phone number on the back of the member’s ID card. 100KF-17532 Please print — accuracy is important. Provider Prior Authorization Form Fax medical authorization requests to: 1.855.328.0059 Phone: Toll-Free 1.844.522.5282 /TDD Relay 1.800.955.8771 Visit myHFHP.org COMPLETE ALL INFORMATION REVIEW TYPE Standard (≤ 14 days) Accommodate scheduling/patient needs (Date needed: _____) Name of Facility: _____ Phone number: Requests that do not include the required information will experience a delay in the approval process. … Look for updated provider materials and communications on this site, and if you have any additional questions, call Keystone First VIP Choice Provider Services at 1-800-521-6007, 8 a.m. – 8 p.m., 7 days a week. Prior radiation treatment. Step 2 – Next, fill in your full name (as the physician Address: Fax Number: Keystone First VIP Choice Urgent: 1-855-516-6381 Attn: Pharmacy Prior Authorization/ Standard: 1-855-516-6380 Member Prescription Coverage Determination PerformRx 200 … Keystone First Find a Provider Text Size: a a a Provider Type: All All PCP Specialists Hospital / Facility Group Dental Please enter a search term such as a doctor's name or a medical specialty. Keystone First is not the member’s primary insurance? Yes, prior authorization is necessary for outpatient advanced imaging, even if Keystone First is not the member’s primary insurance. Keystone First Community HealthChoices(CHC) Prior Authorization Form Facility name: National Provider Identifier (NPI) number: Tax ID: Address: Phone: Fax: Provider Additional therapeutic radiation therapy: Type of radiation therapy. • Keystone First To request access to the TurningPoint Web portal, call the phone numbers listed above. Submitting a prior authorization request via electronic prior authorization (ePA) Did you know… Over two-thirds of the PAs that we receive each year are now electronic. 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. Filled out by a physician or pharmacist, this form must provide clinical reasoning to justify this request being made in lieu of prescribing a drug from the Preferred Drug List (PDL). 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 5/24 Keystone HMO Plans (215) 675-6846 When you purchase a Keystone HMO plan from Independence Blue Cross, you may see any doctor or visit any hospital in the Keystone HMO network. 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