Text. ☐ I request prior authorization for the drug my prescriber has prescribed. hŞbbd```b``º"ï€IkÉ< D²~‘‚³@$g'ˆä“Å ’ÛÌ6‘\×A$ß;0; endstream endobj startxref Your PCP will treat you for general health … Forms are also sent to different fax numbers. 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¯ You also have the option of filling out and submitting an online prior authorization form through their website. For behavioral health prior authorizations, follow these easy steps. %%EOF Pennsylvania (Keystone First) Pennsylvania; San Fransisco (San Fransisco Health Plan) How to Write. Call the prior authorization line at 1-855-294-7046. This information is specific to FFS. † Prior authorization guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs. Keystone First is not responsible for the content of these sites. * ☐ I request an exception to the plan’s limit on the number of pills (quantity limit) I … %PDF-1.7 %âãÏÓ Select formulary prior authorization forms. Provider Manual and Forms. Submitting a prior authorization request via electronic prior authorization (ePA) Members 2020 . Prior Authorization. Please refer to each managed care organization’s (MCO) website for MCO prior authorization procedures, prior authorization fax request forms, and quantity limits. 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 a provider obtains a prior authorization number does that guarantee payment? 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. Download the provider manual (PDF) Forms. This process is called “prior authorization.” Prior authorization process. 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. Submit by fax using the forms posted on the FutureScripts website. Yes, prior authorization is necessary for outpatient advanced imaging, even if Keystone First is not the member’s primary insurance. Prior authorization lookup tool. You pick a primary care physician (PCP), or family doctor, to coordinate your care. Keystone First CHC nurses review the medical information. Prior Authorization Request . Request form instructions Providers. Prior authorization is not a guarantee of payment for the services authorized. 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. 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). Prior authorization is not a guarantee of payment for the service(s) authorized. Using the appropriate form will help assure that we have the information necessary to make a decision about your request. All fields are . 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 Prescription Coverage Determination . Our plan offers members an extensive provider network of physicians, specialists, pharmacies and hospitals. Direct Ship Drug Program. Copyright © 2000-2020 KEYSTONE FAMILY HEALTH PLAN. * ☐ I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception). at . PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION Step 1 – First fill out the patient’s full name, date of birth and ID number. Attachments are optional. 73 Ocean Street, New South Wales 2000, SYDNEY. This site contains links to other Internet sites. ... Keystone First is not responsible for the content of these sites. Claims project submission form (XLS) Critical incident report (PDF) DHS MA-112 newborn form (PDF) Diaper and incontinence supply prescription form (PDF) Services Requiring Prior Authorization. Services that require prior authorization by Keystone First VIP Choice (HMO SNP)** Elective or non-emergent air ambulance transportation. 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). Any additional questions regarding prior authorization requests may be addressed by calling Keystone First's … 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 Request expedited determination for processing within 72 hours. 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. 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 FORM (form effective 1/1/20) Fax to PerformRx. 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. Important payment notice Prior authorizations help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. 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. (recognized formats .pdf, .doc, .xls, .ppt, .txt) Save unique provider information in order to expedite future web submissions. Supporting clinical documentation must be submitted at the time of the request. 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: 1 (215) 937-5018 Attachments. 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 <. 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: It requires that providers receive approval from FutureScripts before prescribing certain medications. 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. 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. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. Y0093_WEB-971045 . Contact Person: Callum S Ansell E: callum.aus@capital.com P: (02) 8252 5319 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, Step Therapy (ST), Quantity Level Limits, and Specialty Medication Lists. Is prior authorization necessary for an outpatient, advanced imaging service if Keystone First is not the member’s primary insurance? 1-215-937-5018, or to speak to a representative call . 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. Please see Terms of Use and Privacy Notice. Make sure you include your office telephone and fax … 1-215-937-5018 ... (If medications were tried prior to enrollment, or if office samples were given, please include.) required. SM. PerformRx . 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. Drü ›¼ÌN³�ƒH�­`¶3�dÜ 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 If needed you can upload and attach files to this request. 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. 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. Independence Blue Cross (Independence) offers a Direct Ship Drug Program to our in-network physicians. 0 PRIOR AUTHORIZATION REQUEST INFORMATION ... 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