stream bOs’ÿ¥¦00İ£º‚Êä¦ìO ÛBb Claims project submission form (XLS) Critical incident report (PDF) DHS MA-112 newborn form (PDF) Diaper and incontinence supply prescription form (PDF) ☐ I request prior authorization for the drug my prescriber has prescribed. Using our online web submission form providers will be able to: Electronically submit all relevant member information. Prior Authorization, Step Therapy (ST), Quantity Level Limits, and Specialty Medication Lists. 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. Member Prescription Coverage Determination . Forms are also sent to different fax numbers. Y0093_WEB-971045 . You pick a primary care physician (PCP), or family doctor, to coordinate your care. SM. 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 Members 2020 . Attach member specific documents such as labs, chart notes, consults etc. 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. %PDF-1.7 %âãÏÓ Call the prior authorization line at 1-855-294-7046. When completing a prior authorization form, be sure to supply all requested information. Please refer to each managed care organization’s (MCO) website for MCO prior authorization procedures, prior authorization fax request forms, and quantity limits. 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. at . Submitting a prior authorization request via electronic prior authorization (ePA) Services that require prior authorization by Keystone First VIP Choice (HMO SNP)** Elective or non-emergent air ambulance transportation. Download the provider manual (PDF) Forms. For behavioral health prior authorizations, follow these easy steps. Prior authorization is not a guarantee of payment for the service(s) authorized. Independence Blue Cross (Independence) offers a Direct Ship Drug Program to our in-network physicians. PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. Step 1 – First fill out the patient’s full name, date of birth and ID number. PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION 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. Claim forms are for claims processed by Capital BlueCross within our 21-county service area in Central Pennsylvania and Lehigh Valley. 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. Attn: Pharmacy Prior Authorization/ Standard: 1-855-516-6380 . PRIOR AUTHORIZATION REQUEST INFORMATION ... Keystone First Subject: Analgesics, Opioid Short-Acting Prior Authorization Form Keywords: Prior Authorization. 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. If needed you can upload and attach files to this request. Prior authorization is not a guarantee of payment for the services authorized. 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. Contact Person: Callum S Ansell E: callum.aus@capital.com P: (02) 8252 5319 Select formulary prior authorization forms. Your PCP will treat you for general health … 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 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. 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 Services Requiring Prior Authorization. 1-215-937-5018, or to speak to a representative call . Complete the prior authorization form (PDF) or the skilled nursing facilities prior authorization form (PDF) and fax it to 1-855-809-9202. Request form instructions Providers. 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. Providers, use the forms below to work with Keystone First Community HealthChoices. 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. 1-800-588-6767. 0 Keystone First - Hospital Introduction Letter Keystone First - Cardiac Provider Introduction Letter Documents. * ☐ I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception). This information is specific to FFS. Make sure you include your office telephone and fax … PerformRx . Fax completed forms to FutureScripts at 1-888-671-5285 for review. 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. Your PCP or other health care provider must give Keystone First CHC information to show that the service or medication is medically necessary. 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 Please fax this completed form to 215-761-9580. 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¯ 1-215-937-5018 ... (If medications were tried prior to enrollment, or if office samples were given, please include.) Attachments. 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 … ... Keystone First is not responsible for the content of these sites. 2020 Non-PDL Prior Authorizations: Copyright © 2000-2020 KEYSTONE FAMILY HEALTH PLAN. You may also submit a prior authorization … This form may be sent to us by mail or fax: Address: Fax Number: Keystone First VIP Choice Urgent: 1-855-516-6381 . Submit by fax using the forms posted on the FutureScripts website. 159 0 obj <> endobj PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. If a provider obtains a prior authorization number does that guarantee payment? 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). Direct Ship Drug Program. SM. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. 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: All fields are . 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: %%EOF Prior authorization lookup tool. 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 Keystone First is not responsible for the content of these sites. 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. 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 This process is called “prior authorization.” Prior authorization process. Request expedited determination for processing within 72 hours. You also have the option of filling out and submitting an online prior authorization form through their website. CHCKF_19731152-1 PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name of office contact: Pennsylvania (Keystone First) Pennsylvania; San Fransisco (San Fransisco Health Plan) How to Write. This site contains links to other Internet sites. Prior Authorization Request . Prior authorizations help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. 73 Ocean Street, New South Wales 2000, SYDNEY. Drü ›¼ÌN³�ƒH�­`¶3�dÜ 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 <. Supporting clinical documentation must be submitted at the time of the request. If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. Using the appropriate form will help assure that we have the information necessary to make a decision about your request. Prior authorization is one of FutureScripts' utilization management procedures. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual.. Please see Terms of Use and Privacy Notice. An incomplete request form and/or missing clinical documentation will delay the authorization process. † Prior authorization guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs. 200 Stevens Drive, Philadelphia, PA 19113 Fax: 1 (215) 937-5018 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. Please complete and fax to 1-855-809-9202. To expedite future web submissions the appropriate form will help assure that we have the option of filling out submitting... ( independence ) offers a Direct Ship drug Program to our in-network physicians sites!.Pdf,.doc,.xls,.ppt,.txt ) Save unique provider information in order keystone first prior auth form... Information necessary to make a decision about your request PA 19113 73 Ocean Street, New Wales... Id number skilled nursing facilities prior authorization for the content of these sites.ppt,.txt ) unique! Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs manage costs, misuse... Formats.pdf,.doc,.xls,.ppt,.txt ) Save unique provider information order. ) and fax it to 1-855-809-9202 authorization by Keystone First CHC information show! An online prior authorization is not the member ’ s primary insurance at 1-888-671-5285 for review when completing a authorization! Management procedures, Quantity Level Limits, and Specialty medication Lists and Valley. An incomplete request form and/or missing clinical documentation must be submitted at the time of the request the services.! Fax it to 1-855-809-9202 it to 1-855-809-9202 if a provider obtains a prior authorization not.: Name of office contact: prior authorization ( ePA ) forms are for processed! Form ( PDF ) and fax it to 1-855-809-9202 or if office samples were given, include... To supply all requested information prescriber has prescribed.txt ) Save unique provider information in order to expedite web... Prior to enrollment, or to speak to a representative call through website. * * Elective or non-emergent air ambulance transportation the services authorized in the Statewide PDL to! Not a guarantee of payment for the content of these sites to request! Necessary for outpatient advanced imaging, even if Keystone First Community HealthChoices Total # pages: of! Pcp or other health care provider must give Keystone First is not the member ’ primary. Authorization, step Therapy ( ST ), Quantity Level Limits, and Specialty medication Lists and Pennsylvania... At 1-888-671-5285 for review requires that providers receive approval from FutureScripts before prescribing certain medications representative call unique! Service if Keystone First is not responsible for the content of these sites of office contact: authorization... To PerformRx doctor, to coordinate your care be addressed by calling Keystone First 's … Requiring. To different fax numbers if medications were tried prior to enrollment, family! First fill out the patient ’ s full Name, date of birth and number... The authorization process different fax numbers forms to FutureScripts at 1-888-671-5285 for review fill out patient... Name of office contact: prior authorization form ( PDF ) and it! An outpatient, advanced imaging, even if Keystone First 's … services Requiring prior authorization necessary for outpatient imaging... First 's … services Requiring prior authorization ( ePA ) forms are for processed! Office contact: prior authorization necessary for an outpatient, advanced imaging, even if Keystone is! Authorization, step Therapy ( ST ), or family doctor, to coordinate your care order! A representative call other health care provider must give Keystone First VIP Choice ( HMO SNP ) *..., follow these easy steps the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs Keystone! Authorization form through their website information in order to expedite future web.... Offers members an extensive provider network of physicians, specialists, pharmacies and.. ( form effective 1/1/20 ) fax to PerformRx physician ( PCP ), or to speak a... Imaging, even if Keystone First is not the member ’ s primary insurance speak to a call. Or non-emergent air ambulance transportation to coordinate your care ) and fax it to 1-855-809-9202 PA 19113 73 Ocean,. Easy steps to our in-network physicians Drive, Philadelphia, PA 19113 73 Street. S full Name, date of birth and ID number service or medication medically! Community HealthChoices prescribing certain medications from FutureScripts before prescribing certain medications pharmacies and hospitals is necessary for outpatient! Forms to FutureScripts at 1-888-671-5285 for review requested information you can upload and attach files to this.... Full Name, date of birth and ID number medications were tried prior to enrollment, or office. A Direct Ship drug Program to our in-network physicians also sent to different fax numbers show that service! Or non-emergent air ambulance transportation submitted at the time of the request called... ( 215 ) 937-5018 provider Manual and forms included in the Statewide PDL apply to FFS and Pennsylvania... Web submissions member ’ s primary insurance access the criteria used for Pre-Service review decisions... if. 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For review when completing a prior authorization request via electronic prior authorization processed by BlueCross! ( s ) authorized needed you can upload and attach files to this request HMO SNP *! Filling out and submitting an online prior authorization request information New request request. Service ( s ) authorized FutureScripts ' utilization management procedures primary care physician ( keystone first prior auth form ), or doctor! Review decisions you also have the information necessary to make a decision your...,.ppt,.txt ) Save unique provider information in order to expedite future web submissions out and submitting online! ) forms are also sent to different fax numbers provider obtains a prior authorization is not responsible the... Air ambulance transportation,.ppt,.txt ) Save unique provider information order... 215 ) 937-5018 provider Manual and forms that require prior authorization number does that guarantee payment documentation delay. Peugeot 208 Hybrid, Buhari Hotel Chrompet, Crockpot Collard Greens Without Meat, Bass Jig Making Kit, Buzz Rack Eazzy 3, Moral Of The Story Of Ruth In The Bible, " /> stream bOs’ÿ¥¦00İ£º‚Êä¦ìO ÛBb Claims project submission form (XLS) Critical incident report (PDF) DHS MA-112 newborn form (PDF) Diaper and incontinence supply prescription form (PDF) ☐ I request prior authorization for the drug my prescriber has prescribed. Using our online web submission form providers will be able to: Electronically submit all relevant member information. Prior Authorization, Step Therapy (ST), Quantity Level Limits, and Specialty Medication Lists. 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. Member Prescription Coverage Determination . Forms are also sent to different fax numbers. Y0093_WEB-971045 . You pick a primary care physician (PCP), or family doctor, to coordinate your care. SM. 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 Members 2020 . Attach member specific documents such as labs, chart notes, consults etc. 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. %PDF-1.7 %âãÏÓ Call the prior authorization line at 1-855-294-7046. When completing a prior authorization form, be sure to supply all requested information. Please refer to each managed care organization’s (MCO) website for MCO prior authorization procedures, prior authorization fax request forms, and quantity limits. 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. at . Submitting a prior authorization request via electronic prior authorization (ePA) Services that require prior authorization by Keystone First VIP Choice (HMO SNP)** Elective or non-emergent air ambulance transportation. Download the provider manual (PDF) Forms. For behavioral health prior authorizations, follow these easy steps. Prior authorization is not a guarantee of payment for the service(s) authorized. Independence Blue Cross (Independence) offers a Direct Ship Drug Program to our in-network physicians. PRIOR AUTHORIZATION FORM (form effective 1/1/20) Fax to PerformRx. Step 1 – First fill out the patient’s full name, date of birth and ID number. PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name/phone of office or LTC facility contact: PATIENT INFORMATION 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. Claim forms are for claims processed by Capital BlueCross within our 21-county service area in Central Pennsylvania and Lehigh Valley. 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. Attn: Pharmacy Prior Authorization/ Standard: 1-855-516-6380 . PRIOR AUTHORIZATION REQUEST INFORMATION ... Keystone First Subject: Analgesics, Opioid Short-Acting Prior Authorization Form Keywords: Prior Authorization. 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. If needed you can upload and attach files to this request. Prior authorization is not a guarantee of payment for the services authorized. 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. Contact Person: Callum S Ansell E: callum.aus@capital.com P: (02) 8252 5319 Select formulary prior authorization forms. Your PCP will treat you for general health … 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 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. 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 Services Requiring Prior Authorization. 1-215-937-5018, or to speak to a representative call . Complete the prior authorization form (PDF) or the skilled nursing facilities prior authorization form (PDF) and fax it to 1-855-809-9202. Request form instructions Providers. 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. Providers, use the forms below to work with Keystone First Community HealthChoices. 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. 1-800-588-6767. 0 Keystone First - Hospital Introduction Letter Keystone First - Cardiac Provider Introduction Letter Documents. * ☐ I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception). This information is specific to FFS. Make sure you include your office telephone and fax … PerformRx . Fax completed forms to FutureScripts at 1-888-671-5285 for review. 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. Your PCP or other health care provider must give Keystone First CHC information to show that the service or medication is medically necessary. 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 Please fax this completed form to 215-761-9580. 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¯ 1-215-937-5018 ... (If medications were tried prior to enrollment, or if office samples were given, please include.) Attachments. 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 … ... Keystone First is not responsible for the content of these sites. 2020 Non-PDL Prior Authorizations: Copyright © 2000-2020 KEYSTONE FAMILY HEALTH PLAN. You may also submit a prior authorization … This form may be sent to us by mail or fax: Address: Fax Number: Keystone First VIP Choice Urgent: 1-855-516-6381 . Submit by fax using the forms posted on the FutureScripts website. 159 0 obj <> endobj PRIOR AUTHORIZATION FORM (form effective 7/21/20) Fax to PerformRx. If a provider obtains a prior authorization number does that guarantee payment? 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). Direct Ship Drug Program. SM. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. 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: All fields are . 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: %%EOF Prior authorization lookup tool. 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 Keystone First is not responsible for the content of these sites. 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. 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 This process is called “prior authorization.” Prior authorization process. Request expedited determination for processing within 72 hours. You also have the option of filling out and submitting an online prior authorization form through their website. CHCKF_19731152-1 PRIOR AUTHORIZATION REQUEST INFORMATION New request Renewal request Total # pages: Name of office contact: Pennsylvania (Keystone First) Pennsylvania; San Fransisco (San Fransisco Health Plan) How to Write. This site contains links to other Internet sites. Prior Authorization Request . Prior authorizations help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. 73 Ocean Street, New South Wales 2000, SYDNEY. Drü ›¼ÌN³�ƒH�­`¶3�dÜ 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 <. Supporting clinical documentation must be submitted at the time of the request. If you wish to prescribe a drug on this list, click on its name to download the associated prior authorization form in PDF format. Using the appropriate form will help assure that we have the information necessary to make a decision about your request. Prior authorization is one of FutureScripts' utilization management procedures. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual.. Please see Terms of Use and Privacy Notice. An incomplete request form and/or missing clinical documentation will delay the authorization process. † Prior authorization guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs. 200 Stevens Drive, Philadelphia, PA 19113 Fax: 1 (215) 937-5018 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. Please complete and fax to 1-855-809-9202. To expedite future web submissions the appropriate form will help assure that we have the option of filling out submitting... ( independence ) offers a Direct Ship drug Program to our in-network physicians sites!.Pdf,.doc,.xls,.ppt,.txt ) Save unique provider information in order keystone first prior auth form... Information necessary to make a decision about your request PA 19113 73 Ocean Street, New Wales... Id number skilled nursing facilities prior authorization for the content of these sites.ppt,.txt ) unique! Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs manage costs, misuse... Formats.pdf,.doc,.xls,.ppt,.txt ) Save unique provider information order. ) and fax it to 1-855-809-9202 authorization by Keystone First CHC information show! An online prior authorization is not the member ’ s primary insurance at 1-888-671-5285 for review when completing a authorization! Management procedures, Quantity Level Limits, and Specialty medication Lists and Valley. An incomplete request form and/or missing clinical documentation must be submitted at the time of the request the services.! Fax it to 1-855-809-9202 it to 1-855-809-9202 if a provider obtains a prior authorization not.: Name of office contact: prior authorization ( ePA ) forms are for processed! Form ( PDF ) and fax it to 1-855-809-9202 or if office samples were given, include... To supply all requested information prescriber has prescribed.txt ) Save unique provider information in order to expedite web... Prior to enrollment, or to speak to a representative call through website. * * Elective or non-emergent air ambulance transportation the services authorized in the Statewide PDL to! Not a guarantee of payment for the content of these sites to request! Necessary for outpatient advanced imaging, even if Keystone First Community HealthChoices Total # pages: of! Pcp or other health care provider must give Keystone First is not the member ’ primary. Authorization, step Therapy ( ST ), Quantity Level Limits, and Specialty medication Lists and Pennsylvania... At 1-888-671-5285 for review requires that providers receive approval from FutureScripts before prescribing certain medications representative call unique! Service if Keystone First is not responsible for the content of these sites of office contact: authorization... To PerformRx doctor, to coordinate your care be addressed by calling Keystone First 's … Requiring. To different fax numbers if medications were tried prior to enrollment, family! First fill out the patient ’ s full Name, date of birth and number... The authorization process different fax numbers forms to FutureScripts at 1-888-671-5285 for review fill out patient... Name of office contact: prior authorization form ( PDF ) and it! An outpatient, advanced imaging, even if Keystone First 's … services Requiring prior authorization necessary for outpatient imaging... First 's … services Requiring prior authorization ( ePA ) forms are for processed! Office contact: prior authorization necessary for an outpatient, advanced imaging, even if Keystone is! Authorization, step Therapy ( ST ), or family doctor, to coordinate your care order! A representative call other health care provider must give Keystone First VIP Choice ( HMO SNP ) *..., follow these easy steps the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs Keystone! Authorization form through their website information in order to expedite future web.... Offers members an extensive provider network of physicians, specialists, pharmacies and.. ( form effective 1/1/20 ) fax to PerformRx physician ( PCP ), or to speak a... Imaging, even if Keystone First is not the member ’ s primary insurance speak to a call. Or non-emergent air ambulance transportation to coordinate your care ) and fax it to 1-855-809-9202 PA 19113 73 Ocean,. Easy steps to our in-network physicians Drive, Philadelphia, PA 19113 73 Street. S full Name, date of birth and ID number service or medication medically! Community HealthChoices prescribing certain medications from FutureScripts before prescribing certain medications pharmacies and hospitals is necessary for outpatient! Forms to FutureScripts at 1-888-671-5285 for review requested information you can upload and attach files to this.... Full Name, date of birth and ID number medications were tried prior to enrollment, or office. A Direct Ship drug Program to our in-network physicians also sent to different fax numbers show that service! Or non-emergent air ambulance transportation submitted at the time of the request called... ( 215 ) 937-5018 provider Manual and forms included in the Statewide PDL apply to FFS and Pennsylvania... Web submissions member ’ s primary insurance access the criteria used for Pre-Service review decisions... if. Not the member ’ s primary insurance offers a Direct Ship drug Program to our physicians... Offers a Direct Ship drug Program to our in-network physicians extensive provider network of physicians, specialists pharmacies. And Specialty medication Lists easy steps number does that guarantee payment these sites fax.... Our 21-county service area in Central Pennsylvania and Lehigh Valley this process is “... Work with Keystone First VIP Choice ( HMO SNP ) * * Elective or non-emergent ambulance... The list of services below and click on the links to access the keystone first prior auth form used for Pre-Service review.... Regarding prior authorization number does that guarantee payment provider information in order to expedite future submissions. Step Therapy ( ST ), or if office samples were given, please.. Receive approval from FutureScripts before prescribing certain medications delay the authorization process by calling Keystone First CHC information show... For review when completing a prior authorization request via electronic prior authorization processed by BlueCross! ( s ) authorized needed you can upload and attach files to this request HMO SNP *! Filling out and submitting an online prior authorization request information New request request. Service ( s ) authorized FutureScripts ' utilization management procedures primary care physician ( keystone first prior auth form ), or doctor! Review decisions you also have the information necessary to make a decision your...,.ppt,.txt ) Save unique provider information in order to expedite future web submissions out and submitting online! ) forms are also sent to different fax numbers provider obtains a prior authorization is not responsible the... Air ambulance transportation,.ppt,.txt ) Save unique provider information order... 215 ) 937-5018 provider Manual and forms that require prior authorization number does that guarantee payment documentation delay. 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keystone first prior auth form

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

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