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Keystone First is not responsible for the content of these sites. 1-800-588-6767. 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 <. Prior authorization is not a guarantee of payment for the services authorized. If needed you can upload and attach files to this request. Member Prescription Coverage Determination . When completing a prior authorization form, be sure to supply all requested information. 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. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual.. Using our online web submission form providers will be able to: Electronically submit all relevant member information. Prior authorization is not a guarantee of payment for the service(s) authorized. PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION Is prior authorization necessary for an outpatient, advanced imaging service if Keystone First is not the member’s primary insurance? 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 Complete the prior authorization form (PDF) or the skilled nursing facilities prior authorization form (PDF) and fax it to 1-855-809-9202. Download the provider manual (PDF) Forms. Our plan offers members an extensive provider network of physicians, specialists, pharmacies and hospitals. SM. It requires that providers receive approval from FutureScripts before prescribing certain medications. 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. 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. This process is called “prior authorization.” Prior authorization process. You may also submit a prior authorization … Select formulary prior authorization forms. Keystone First CHC nurses review the medical information. 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. Prior authorization is one of FutureScripts' utilization management procedures. 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. Step 1 – First fill out the patient’s full name, date of birth and ID number. 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: 198 0 obj <>stream 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. Claims project submission form (XLS) Critical incident report (PDF) DHS MA-112 newborn form (PDF) Diaper and incontinence supply prescription form (PDF) Make sure you include your office telephone and fax … Drü ›¼ÌN³�ƒH�­`¶3�dÜ Provider Manual and Forms. Yes, prior authorization is necessary for outpatient advanced imaging, even if Keystone First is not the member’s primary insurance. 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. * ☐ I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception). 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. If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. required. Fax: 1 (215) 937-5018 endstream endobj startxref Please see Terms of Use and Privacy Notice. %%EOF Providers, use the forms below to work with Keystone First Community HealthChoices. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. All fields are . Services Requiring Prior Authorization. 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. Text. * ☐ I request an exception to the plan’s limit on the number of pills (quantity limit) I … Y0093_WEB-971045 . SM. Prior Authorization Request . Prior Authorization, Step Therapy (ST), Quantity Level Limits, and Specialty Medication Lists. ☐ I request prior authorization for the drug my prescriber has prescribed. 1-215-937-5018, or to speak to a representative call . Fax completed forms to FutureScripts at 1-888-671-5285 for review. Please fax this completed form to 215-761-9580. 2020 Non-PDL Prior Authorizations: 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. You also have the option of filling out and submitting an online prior authorization form through their website. 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. 200 Stevens Drive, Philadelphia, PA 19113 Your PCP will treat you for general health … Members 2020 . Any additional questions regarding prior authorization requests may be addressed by calling Keystone First's … Attn: Pharmacy Prior Authorization/ Standard: 1-855-516-6380 . You pick a primary care physician (PCP), or family doctor, to coordinate your care. 159 0 obj <> endobj Independence Blue Cross (Independence) offers a Direct Ship Drug Program to our in-network physicians. An incomplete request form and/or missing clinical documentation will delay the authorization process. 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. 0 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 Services that require prior authorization by Keystone First VIP Choice (HMO SNP)** Elective or non-emergent air ambulance transportation. If a provider obtains a prior authorization number does that guarantee payment? Pennsylvania (Keystone First) Pennsylvania; San Fransisco (San Fransisco Health Plan) How to Write. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. %PDF-1.7 %âãÏÓ PRIOR AUTHORIZATION REQUEST INFORMATION ... Keystone First Subject: Analgesics, Opioid Short-Acting Prior Authorization Form Keywords: 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. This site contains links to other Internet sites. Please complete and fax to 1-855-809-9202. Copyright © 2000-2020 KEYSTONE FAMILY HEALTH PLAN. Attachments. Submit by fax using the forms posted on the FutureScripts website. (recognized formats .pdf, .doc, .xls, .ppt, .txt) Save unique provider information in order to expedite future web submissions. Direct Ship Drug Program. For behavioral health prior authorizations, follow these easy steps. Contact Person: Callum S Ansell E: [email protected] P: (02) 8252 5319 hŞb``a``Ve```*[email protected]Œ@ÌÂÀÑ a3•Y0€U3ˆ�e;˜¹X²„8yz¸_s­áYÅéÏ›Æy‰½€Q‡ı£=¿.ãîõ½S÷ô]`ä…ÉÊÀÔ´j4ã,¸5˜€™�©"ä,.¸(Ó̯=Œ� 79¯ 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 CHCKF_19731152-1 PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name of office contact: 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. This form may be sent to us by mail or fax: Address: Fax Number: Keystone First VIP Choice Urgent: 1-855-516-6381 . bOs’ÿ¥¦00İ£º‚Êä¦ìO ÛBb Submitting a prior authorization request via electronic prior authorization (ePA) Attachments are optional. 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. 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). Attach member specific documents such as labs, chart notes, consults etc. Supporting clinical documentation must be submitted at the time of the request. 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 Please refer to each managed care organization’s (MCO) website for MCO prior authorization procedures, prior authorization fax request forms, and quantity limits. Prior Authorization. PerformRx . PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. at . Request form instructions Providers. 1-215-937-5018 ... (If medications were tried prior to enrollment, or if office samples were given, please include.) Your PCP or other health care provider must give Keystone First CHC information to show that the service or medication is medically necessary. 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. Call the prior authorization line at 1-855-294-7046. Request expedited determination for processing within 72 hours. 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: Claim forms are for claims processed by Capital BlueCross within our 21-county service area in Central Pennsylvania and Lehigh Valley. Prior authorization lookup tool. ... Keystone First is not responsible for the content of these sites. Forms are also sent to different fax numbers. hŞbbd```b``º"ï€IkÉ< D²~‘‚³@$g'ˆä“Å ’ÛÌ6‘\×A$ß;0; Using the appropriate form will help assure that we have the information necessary to make a decision about your request. at . Keystone First - Hospital Introduction Letter Keystone First - Cardiac Provider Introduction Letter Documents. 73 Ocean Street, New South Wales 2000, SYDNEY. 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 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). 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