This process is called “prior authorization.” Prior authorization process. For behavioral health prior authorizations, follow these easy steps. Please see Terms of Use and Privacy Notice. 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 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 at . If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. Call the prior authorization line at 1-855-294-7046. Your PCP or other health care provider must give Keystone First CHC information to show that the service or medication is medically necessary. Attach member specific documents such as labs, chart notes, consults etc. 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. 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. Keystone First - Hospital Introduction Letter Keystone First - Cardiac Provider Introduction Letter Documents. Download the provider manual (PDF) Forms. PerformRx . 2020 Non-PDL Prior Authorizations: 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: at . Prior Authorization. 0 You pick a primary care physician (PCP), or family doctor, to coordinate your care. Step 1 – First fill out the patient’s full name, date of birth and ID number. Your PCP will treat you for general health … 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 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. Keystone First is not responsible for the content of these sites. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. Please refer to each managed care organization’s (MCO) website for MCO prior authorization procedures, prior authorization fax request forms, and quantity limits. 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). Attachments are optional. endstream endobj startxref 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. Request form instructions Providers. Forms are also sent to different fax numbers. 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. Prior Authorization Request . Prior authorization is one of FutureScripts' utilization management procedures. 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. Using our online web submission form providers will be able to: Electronically submit all relevant member information. 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. Complete the prior authorization form (PDF) or the skilled nursing facilities prior authorization form (PDF) and fax it to 1-855-809-9202. Select formulary prior authorization forms. Using the appropriate form will help assure that we have the information necessary to make a decision about your request. Y0093_WEB-971045 . † Prior authorization guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs. Fax completed forms to FutureScripts at 1-888-671-5285 for review. It requires that providers receive approval from FutureScripts before prescribing certain medications. * ☐ I request an exception to the plan’s limit on the number of pills (quantity limit) I … 1-800-588-6767. SM. Submit by fax using the forms posted on the FutureScripts website. Members 2020 . If needed you can upload and attach files to this request. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. You also have the option of filling out and submitting an online prior authorization form through their website. Please complete and fax to 1-855-809-9202. Attn: Pharmacy Prior Authorization/ Standard: 1-855-516-6380 . Yes, prior authorization is necessary for outpatient advanced imaging, even if Keystone First is not the member’s primary insurance. Independence Blue Cross (Independence) offers a Direct Ship Drug Program to our in-network physicians. %%EOF Provider Manual and Forms. This form may be sent to us by mail or fax: Address: Fax Number: Keystone First VIP Choice Urgent: 1-855-516-6381 . 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 REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION Contact Person: Callum S Ansell E: callum.aus@capital.com P: (02) 8252 5319 This site contains links to other Internet sites. Prior Authorization, Step Therapy (ST), Quantity Level Limits, and Specialty Medication Lists. An incomplete request form and/or missing clinical documentation will delay the authorization process. bOs’ÿ¥¦00İ£º‚Êä¦ìO ÛBb hŞbbd```b``º"ï€IkÉ< D²~‘‚³@$g'ˆä“Å ’ÛÌ6‘\×A$ß;0; Providers, use the forms below to work with Keystone First Community HealthChoices. When completing a prior authorization form, be sure to supply all requested information. 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. Is prior authorization necessary for an outpatient, advanced imaging service if Keystone First is not the member’s primary insurance? SM. Services that require prior authorization by Keystone First VIP Choice (HMO SNP)** Elective or non-emergent air ambulance transportation. Direct Ship Drug Program. Submitting a prior authorization request via electronic prior authorization (ePA) Drü ›¼ÌN³�ƒH�­`¶3�dÜ CHCKF_19731152-1 PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name of office contact: This information is specific to FFS. If a provider obtains a prior authorization number does that guarantee payment? 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). 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. 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: 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¯ Claims project submission form (XLS) Critical incident report (PDF) DHS MA-112 newborn form (PDF) Diaper and incontinence supply prescription form (PDF) PRIOR AUTHORIZATION REQUEST INFORMATION ... Keystone First Subject: Analgesics, Opioid Short-Acting Prior Authorization Form Keywords: Services Requiring Prior Authorization. All fields are . You may also submit a prior authorization … Text. ☐ I request prior authorization for the drug my prescriber has prescribed. Our plan offers members an extensive provider network of physicians, specialists, pharmacies and hospitals. Supporting clinical documentation must be submitted at the time of the request. Make sure you include your office telephone and fax … Prior authorization is not a guarantee of payment for the service(s) authorized. 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. 1-215-937-5018, or to speak to a representative call . 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 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. 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. 198 0 obj <>stream 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 Member Prescription Coverage Determination . Attachments. 200 Stevens Drive, Philadelphia, PA 19113 Pennsylvania (Keystone First) Pennsylvania; San Fransisco (San Fransisco Health Plan) How to Write. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual.. ... Keystone First is not responsible for the content of these sites. Important payment notice 73 Ocean Street, New South Wales 2000, SYDNEY. Request expedited determination for processing within 72 hours. (recognized formats .pdf, .doc, .xls, .ppt, .txt) Save unique provider information in order to expedite future web submissions. 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. 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. Prior authorization is not a guarantee of payment for the services authorized. Fax: 1 (215) 937-5018 Prior authorization lookup tool. 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 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. 1-215-937-5018 ... (If medications were tried prior to enrollment, or if office samples were given, please include.) 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