Please refer to each managed care organization’s (MCO) website for MCO prior authorization procedures, prior authorization fax request forms, and quantity limits. 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. * ☐ I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception). Request form instructions Providers. Attach member specific documents such as labs, chart notes, consults etc. Prior Authorization Request . Attn: Pharmacy Prior Authorization/ Standard: 1-855-516-6380 . Download the provider manual (PDF) Forms. at . 159 0 obj <> endobj 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 Y0093_WEB-971045 . ... Keystone First is not responsible for the content of these sites. PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION Supporting clinical documentation must be submitted at the time of the request. Prior Authorization, Step Therapy (ST), Quantity Level Limits, and Specialty Medication Lists. If a provider obtains a prior authorization number does that guarantee payment? Step 1 – First fill out the patient’s full name, date of birth and ID number. 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. Services Requiring Prior Authorization. Members 2020 . Fax completed forms to FutureScripts at 1-888-671-5285 for review. All fields are . 73 Ocean Street, New South Wales 2000, SYDNEY. 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. It requires that providers receive approval from FutureScripts before prescribing certain medications. Call the prior authorization line at 1-855-294-7046. Yes, prior authorization is necessary for outpatient advanced imaging, even if Keystone First is not the member’s primary insurance. 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. For behavioral health prior authorizations, follow these easy steps. Keystone First - Hospital Introduction Letter Keystone First - Cardiac Provider Introduction Letter Documents. Pennsylvania (Keystone First) Pennsylvania; San Fransisco (San Fransisco Health Plan) How to Write. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. † Prior authorization guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs. SM. bOs’ÿ¥¦00İ£º‚Êä¦ìO ÛBb View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. Prior authorization is not a guarantee of payment for the services authorized. required. When completing a prior authorization form, be sure to supply all requested information. If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. Forms are also sent to different fax numbers. Keystone First CHC nurses review the medical information. * ☐ I request an exception to the plan’s limit on the number of pills (quantity limit) I … SM. Provider Manual and Forms. 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 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. If needed you can upload and attach files to this request. Using the appropriate form will help assure that we have the information necessary to make a decision about your request. 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 <. %%EOF Submitting a prior authorization request via electronic prior authorization (ePA) Please fax this completed form to 215-761-9580. Fax: 1 (215) 937-5018 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.) 198 0 obj <>stream 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 %PDF-1.7 %âãÏÓ hŞbbd```b``º"ï€IkÉ< D²~‘‚³@$g'ˆä“Å ’ÛÌ6‘\×A$ß;0; 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: Any additional questions regarding prior authorization requests may be addressed by calling Keystone First's … PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. 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 REQUEST INFORMATION ... Keystone First Subject: Analgesics, Opioid Short-Acting Prior Authorization Form Keywords: Select formulary prior authorization forms. (recognized formats .pdf, .doc, .xls, .ppt, .txt) Save unique provider information in order to expedite future web submissions. Your PCP or other health care provider must give Keystone First CHC information to show that the service or medication is medically necessary. Member Prescription Coverage Determination . Attachments. 0 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 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. Using our online web submission form providers will be able to: Electronically submit all relevant member information. You also have the option of filling out and submitting an online prior authorization form through their website. 200 Stevens Drive, Philadelphia, PA 19113 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. at . Contact Person: Callum S Ansell E: callum.aus@capital.com P: (02) 8252 5319 endstream endobj startxref Submit by fax using the forms posted on the FutureScripts website. Copyright © 2000-2020 KEYSTONE FAMILY HEALTH PLAN. 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). Prior authorization lookup tool. 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 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: Providers, use the forms below to work with Keystone First Community HealthChoices. 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. This form may be sent to us by mail or fax: Address: Fax Number: Keystone First VIP Choice Urgent: 1-855-516-6381 . Prior authorizations help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. Please complete and fax to 1-855-809-9202. You pick a primary care physician (PCP), or family doctor, to coordinate your care. Prior Authorization. 1-800-588-6767. 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. 2020 Non-PDL Prior Authorizations: This information is specific to FFS. 1-215-937-5018, or to speak to a representative call . Is prior authorization necessary for an outpatient, advanced imaging service if Keystone First is not the member’s primary insurance? A prior authorization is not the member ’ s primary insurance of '.,.ppt,.txt ) Save unique provider information in order to expedite future submissions... 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