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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. 73 Ocean Street, New South Wales 2000, SYDNEY. Copyright © 2000-2020 KEYSTONE FAMILY HEALTH PLAN. 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. Drü ›¼ÌN³�ƒH�­`¶3�dÜ Important payment notice 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. 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. 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 … 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. 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 <. Yes, prior authorization is necessary for outpatient advanced imaging, even if Keystone First is not the member’s primary insurance. 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. at . Select formulary prior authorization forms. 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. Using our online web submission form providers will be able to: Electronically submit all relevant member information. 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. Is prior authorization necessary for an outpatient, advanced imaging service if Keystone First is not the member’s primary insurance? PRIOR AUTHORIZATION REQUEST INFORMATION ... Keystone First Subject: Analgesics, Opioid Short-Acting Prior Authorization Form Keywords: Please fax this completed form to 215-761-9580. † Prior authorization guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs. ☐ I request prior authorization for the drug my prescriber has prescribed. bOs’ÿ¥¦00İ£º‚Êä¦ìO ÛBb All fields are . Member Prescription Coverage Determination . 198 0 obj <>stream Y0093_WEB-971045 . For behavioral health prior authorizations, follow these easy steps. This process is called “prior authorization.” Prior authorization process. %PDF-1.7 %âãÏÓ Call the prior authorization line at 1-855-294-7046. ... Keystone First is not responsible for the content of these sites. Attach member specific documents such as labs, chart notes, consults etc. hŞbbd```b``º"ï€IkÉ< D²~‘‚³@$g'ˆä“Å ’ÛÌ6‘\×A$ß;0; If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. Please complete and fax to 1-855-809-9202. SM. Please see Terms of Use and Privacy Notice. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. Fax: 1 (215) 937-5018 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 REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION Prior authorization is not a guarantee of payment for the services authorized. 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: 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. Services that require prior authorization by Keystone First VIP Choice (HMO SNP)** Elective or non-emergent air ambulance transportation. 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. Prior Authorization Request . Prior authorizations help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. * ☐ I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception). 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. Attn: Pharmacy Prior Authorization/ Standard: 1-855-516-6380 . Attachments are optional. required. 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. endstream endobj startxref An incomplete request form and/or missing clinical documentation will delay the authorization process. Our plan offers members an extensive provider network of physicians, specialists, pharmacies and hospitals. Submit by fax using the forms posted on the FutureScripts website. 1-800-588-6767. Independence Blue Cross (Independence) offers a Direct Ship Drug Program to our in-network physicians. 2020 Non-PDL Prior Authorizations: Using the appropriate form will help assure that we have the information necessary to make a decision about your request. 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 You may also submit a prior authorization … Any additional questions regarding prior authorization requests may be addressed by calling Keystone First's … Forms are also sent to different fax numbers. Keystone First CHC nurses review the medical information. You also have the option of filling out and submitting an online prior authorization form through their website. Keystone First is not responsible for the content of these sites. Provider Manual and Forms. 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 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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