Provider Manual and Forms. Prior Authorization. Make sure you include your office telephone and fax … To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual.. %%EOF Attach member specific documents such as labs, chart notes, consults etc. 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. 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 Claim forms are for claims processed by Capital BlueCross within our 21-county service area in Central Pennsylvania and Lehigh Valley. If a provider obtains a prior authorization number does that guarantee payment? Yes, prior authorization is necessary for outpatient advanced imaging, even if Keystone First is not the member’s primary insurance. ... Keystone First is not responsible for the content of these sites. Please see Terms of Use and Privacy Notice. Step 1 – First fill out the patient’s full name, date of birth and ID number. 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). It requires that providers receive approval from FutureScripts before prescribing certain medications. 73 Ocean Street, New South Wales 2000, SYDNEY. 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. 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. Prior authorization lookup tool. 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. Prior authorizations help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. Download the provider manual (PDF) Forms. 1-800-588-6767. Submitting a prior authorization request via electronic prior authorization (ePA) 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. Complete the prior authorization form (PDF) or the skilled nursing facilities prior authorization form (PDF) and fax it to 1-855-809-9202. 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 Request form instructions Providers. 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 Attn: Pharmacy Prior Authorization/ Standard: 1-855-516-6380 . Providers, use the forms below to work with Keystone First Community HealthChoices. Keystone First is not responsible for the content of these sites. 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. Submit by fax using the forms posted on the FutureScripts website. 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. 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: Y0093_WEB-971045 . † Prior authorization guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs. Prior Authorization, Step Therapy (ST), Quantity Level Limits, and Specialty Medication Lists. hŞbbd```b``º"ï€IkÉ< D²~‘‚³@$g'ˆä“Å ’ÛÌ6‘\×A$ß;0; 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. An incomplete request form and/or missing clinical documentation will delay the authorization process. This form may be sent to us by mail or fax: Address: Fax Number: Keystone First VIP Choice Urgent: 1-855-516-6381 . Important payment notice Drü ›¼ÌN³�ƒH�­`¶3�dÜ Prior authorization is not a guarantee of payment for the services authorized. All fields are . endstream endobj startxref Member Prescription Coverage Determination . For behavioral health prior authorizations, follow these easy steps. at . If needed you can upload and attach files to this request. (recognized formats .pdf, .doc, .xls, .ppt, .txt) Save unique provider information in order to expedite future web submissions. If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. 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. Independence Blue Cross (Independence) offers a Direct Ship Drug Program to our in-network physicians. Please refer to each managed care organization’s (MCO) website for MCO prior authorization procedures, prior authorization fax request forms, and quantity limits. 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. Fax completed forms to FutureScripts at 1-888-671-5285 for review. Text. PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION at . 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 1/1/20) Fax to PerformRx. Using the appropriate form will help assure that we have the information necessary to make a decision about your request. Copyright © 2000-2020 KEYSTONE FAMILY HEALTH PLAN. PerformRx . 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 <. 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. Attachments are optional. Please fax this completed form to 215-761-9580. Claims project submission form (XLS) Critical incident report (PDF) DHS MA-112 newborn form (PDF) Diaper and incontinence supply prescription form (PDF) 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. * ☐ I request an exception to the plan’s limit on the number of pills (quantity limit) I … 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. 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. Any additional questions regarding prior authorization requests may be addressed by calling Keystone First's … SM. Direct Ship Drug Program. Services Requiring Prior Authorization. Your PCP or other health care provider must give Keystone First CHC information to show that the service or medication is medically necessary. Forms are also sent to different fax numbers. PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. Services that require prior authorization by Keystone First VIP Choice (HMO SNP)** Elective or non-emergent air ambulance transportation. You pick a primary care physician (PCP), or family doctor, to coordinate your care. Attachments. CHCKF_19731152-1 PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name of office contact: Prior authorization is one of FutureScripts' utilization management procedures. Prior Authorization Request . 1-215-937-5018, or to speak to a representative call . Contact Person: Callum S Ansell E: callum.aus@capital.com P: (02) 8252 5319 An online prior authorization form ( form effective 1/1/20 ) fax to PerformRx files keystone first prior auth form. 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