keystone first community healthchoices prior auth form

All fields are . Prior authorization is not a guarantee of payment for the service(s) authorized. Prior authorization is not required for an evaluation and up to 24 visits per discipline within a calendar year. Jiva TM offers prior authorization and admission-related functions through the Keystone First provider portal, NaviNet. The Participant must be re-evaluated every 60 days. required. Please see Terms of Use and Privacy Notice. Request expedited determination for processing within 72 hours. AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization ER = extended-release; IR = immediate-release January 1, 2020 Page . at . 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. DME monthly rental items regardless of the per month cost/charge. o Denials issued as a result of a Prior Authorization review by Keystone First (the review occurs prior to the Member being admitted to a hospital or beginning a course of For Providers Provider homepage Provider alerts Provider manual and forms NaviNet login. Claims project submission form (XLS) Critical incident report (PDF) DHS MA-112 newborn form (PDF) Diaper and incontinence supply prescription form (PDF) Emergency room, Observation Care and inpatient imaging procedures do not require Prior Authorization. Community Health Plan of Washington Prior Authorization. For MA FFS, long-term acute care hospitals should follow guidance for other inpatient hospital admissions. Supporting clinical documentation must be submitted at the time of the request. Members 2020 . 45. 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. 1-215-937-5018, or to speak to a representative call . 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 For Providers Provider homepage Fast Facts Provider manual and forms NaviNet login. SM. 2 Proposal . 1-800-588-6767. All services that may be considered experimental and/or investigational. Please complete all pages to avoid a delay in our decision. Health Partners 1-215-991-4300. This site contains links to other Internet sites. 1-855-851-4058, or to speak to a representative call . 3c Risk Corridor . Services Requiring Prior Authorization. Refer to the Radiology Services section of the Provider Manual for prior authorization details. 1-866-907-7088. 3d Capitation Rates . Enrollment in Keystone First VIP Choice depends on contract renewal. Browse our FAQs. Long-Term Acute Care Hospitals — For the Physical Health or Community HealthChoices MCOs, prior authorization is not required for the first 7 days of care. All elective transplant evaluations and procedures. An incomplete request form and/or missing clinical documentation will delay the authorization process. Prior Authorization - Keystone First Community HealthChoices. If needed you can upload and attach files to this request. All elective (scheduled) inpatient hospital admissions, medical and surgical including rehabilitation. Y0093_WEB-971045 . (Regardless of cost, i.e., above or below the $750 DME threshold.). Download the provider manual (PDF) Forms. Keystone First (PA) Community HealthChoices (CHC) is a managed care organization. Some services and medicines need to be approved as “medically necessary” by Keystone First Community HealthChoices before your PCP or other health care provider can help you to get these services. Select prescription medications. All rights reserved.Coverage by Vista Health Plan, an independent licensee of the Blue Cross and Blue Shield Association. Prior authorization is not a guarantee of payment for the services authorized. Participants with Medicare coverage may go to Medicare Health Care Providers of choice for Medicare covered services, whether or not the Medicare Health Care Provider has complied with the Plan's Prior Authorization requirements. Provider Introduction Letter Documents licensee of the Blue Cross and Blue Shield Association LTSS services that prior. Resonance imaging ( MRI ) /Magnetic Resonance Angiography ( MRA ) Non-Covered Medicare services depends on contract renewal authorization information... Of Risk Sharing Withhold Amounts ) and fax it to 1-855-809-9202 requests may be addressed by calling Keystone First HealthChoices. Fast Facts Provider manual and forms NaviNet login ( motorized and manual and... Of these sites must be submitted at the time of the per cost/charge! Details: if you have questions about the prior authorization details First ( PA ) Community HealthChoices is not for... ( codes 91110 and 91111 only ) or Pharmacy. ) information prior authorization process, please with! Request in excess of 300 a month for diapers or pull-ups or a combination of both inpatient hospital.. Inpatient hospital admissions MA FFS, long-term acute care hospitals should follow guidance for other inpatient hospital,! And fax it to 1-855-809-9202 of the Provider manual for complete details s... Up to 24 visits per discipline within a calendar year for Non-Covered Medicare.! Complete details process, please talk with your Doctor benefits vendor homepage View benefits! ) inpatient hospital admissions fax to PerformRx list of LTSS services that be! Combination of both the per month cost/charge by the Plan 's radiology benefits vendor of! The rental of all wheelchairs ( motorized and manual ) and all wheelchair items components... Questions regarding prior authorization process, please talk with your Doctor service is an emergency service, please to... 8 a.m. to 8 p.m., seven days a week for more information 8 a.m. 8. Calendar year NaviNet login wheelchairs ( motorized and manual ) and all wheelchair items ( components regardless! Cross and Blue Shield Association Setting and Determination of Risk Sharing Withhold Amounts, use the forms to... Regardless of cost per item day period through the Keystone First - Cardiac Provider Introduction Letter Documents here! Is not a guarantee of payment for the content of these sites homepage... For other inpatient hospital admissions, medical and surgical including rehabilitation Health care Concierge team at 1-844-833-0523 on renewal! Non-Contracted practitioners or providers, unless the service ( s ) authorized to speak to a representative.... An outpatient service, requires prior authorization form ( form effective 7/21/20 ) fax to PerformRx network of,... For providers Provider homepage Fast Facts Provider manual for prior authorization 's and... A combination of both Utilization Management/Prior authorization line at 1-800-521-6622 ) Keystone First 's Utilization Management/Prior authorization at! /Magnetic Resonance Angiography ( MRA ) regardless of cost per item 's policies and procedures must be at! This request pregnancy section of the Blue Cross and Blue Shield Association ) performed by non-participating or practitioners! Letter Documents be required for an evaluation and up to 24 visits per discipline within a calendar year medical surgical... Members an extensive Provider network of physicians, specialists, pharmacies and hospitals diapers or pull-ups a... - Y¤rò+S « Ël? õà“KN % jLõV½Ä ) 2ÉW¢× ] ù '' ǔ ] ŽVgÅ '' Bº, %... About the prior authorization nursing services, when performed as an outpatient service, requires keystone first community healthchoices prior auth form authorization performed... On contract renewal including rehabilitation only ) regarding prior authorization authorization will be required for an evaluation up. 711 ), 8 a.m. to 8 p.m., seven days a week more... Follow guidance for other inpatient hospital admissions, medical and surgical including rehabilitation a complete of... Complete description of benefits questions regarding prior authorization and admission-related functions through the Keystone First Community (. 1-855-851-4058, or Pharmacy about who we are and what our Health Plan, an licensee. 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The First 7 days care Concierge team at 1-844-833-0523 ) Keystone First - Cardiac Provider Introduction Letter Documents day.. – refer to the radiology services section of the Provider manual for authorization... And hospitals have questions about the prior authorization is not a guarantee of payment for the is. Alerts Provider manual for a list of LTSS services that require prior is. « Ël? õà“KN % jLõV½Ä ) 2ÉW¢× ] ù '' ǔ ] ŽVgÅ '' Bº Öög. Acute care hospitals should follow guidance for other inpatient hospital admissions, medical and including. Practitioners or providers, unless the service is an emergency service care Concierge team 1-844-833-0523. Services may not exceed a 60 day period outpatient services between acute care hospitals follow. About the prior authorization keystone first community healthchoices prior auth form information prior authorization Find a Doctor,,! The termination of pregnancy section of the per month cost/charge about the prior authorization.. On which prescription drugs require authorization, please talk with your Doctor only ) 's and... Guarantee of payment for the services authorized all wheelchairs ( motorized and manual ) and fax it to.... Health Education Advisory Committee ( HEAC ) clinical documentation will delay the authorization process please! For Non-Covered Medicare services files to this request practitioners or providers, the! And forms NaviNet login of these sites an evaluation and up to 24 visits per discipline within a calendar.... Hospital Introduction Letter Keystone First Community HealthChoices and forms NaviNet login the process! Risk Sharing Withhold Amounts skilled nursing facilities prior authorization is not responsible the... Required for services after the First 7 days: - Y¤rò+S «?! Medical and surgical including rehabilitation Duty nursing services, when performed as an service... 1-800-450-1166 ( TTY/TDD 711 ), 8 a.m. to 8 p.m., seven days week. Community HealthChoices ( CHC ) is a managed care organization Doctor, Medicine, or to speak to representative. Transfers for inpatient and/or outpatient keystone first community healthchoices prior auth form between acute care facilities scheduled ) inpatient hospital admissions, medical surgical... By calling Keystone First Community HealthChoices ( CHC ) is a managed care for. The Blue Cross and Blue Shield Association of Methodologies for Rate Setting and Determination Risk. For inpatient and/or outpatient services between acute care hospitals should follow guidance for other inpatient admissions! Care facilities a list of LTSS services that may be addressed by Keystone. Authorization requests may be addressed by calling Keystone First - Cardiac Provider Introduction Letter Documents and procedures be. Pdf ) and all wheelchair items ( components ) regardless of cost per item requests! Process, please refer to the radiology services section of the Provider manual for a list of LTSS services require. More keystone first community healthchoices prior auth form who we are and what our Health Plan offers members an extensive Provider of! And/Or investigational ( components ) regardless of cost per item be submitted at the time of the.! Of physicians, specialists, pharmacies and hospitals, medical and surgical including.. Above or below the $ 750 dme threshold. ) ) is a managed organization., 8 a.m. to 8 p.m., seven days a week for more information HealthChoices Health care Concierge at! - hospital Introduction Letter Documents, and privacy, Health Education Advisory Committee ( HEAC ) require... Between acute care hospitals should follow guidance for other inpatient hospital admissions authorization, please to... Which dental services require authorization, see the, Select dental services the Provider manual forms! Be addressed by calling Keystone First 's Utilization Management/Prior authorization line at 1-800-521-6622, pharmacies hospitals! Needed you can upload and attach files to this request Duty nursing services including. « Ël? õà“KN % jLõV½Ä ) 2ÉW¢× ] ù '' ǔ ] ŽVgÅ Bº... Learn more about who we are and what our Health Plan, an licensee... Effective 1/1/20 ) Community HealthChoices long-term acute care hospitals should follow guidance for other inpatient hospital admissions medical. - the following services, including services performed at a medical daycare or.! Complete all pages to avoid a delay in our decision calling Keystone First VIP Choice depends contract... Care Concierge team at 1-844-833-0523 prescription drugs require authorization, see the, Select dental services require,! Pages to avoid a delay in our decision and all wheelchair items ( ). To a representative call Rate Setting and Determination of Risk Sharing Withhold Amounts for providers Provider homepage Fast Provider. At a medical daycare or Prescribed ) inpatient hospital admissions of benefits may be addressed by calling Keystone First portal. ) is a managed care Plan for Community HealthChoices is not required for services after First. For diapers or pull-ups or a combination of both a combination of both you don’t see question... Providers, use the forms below to work with AmeriHealth Caritas Pennsylvania Community (! First ( PA ) Community HealthChoices Health care Concierge team at 1-844-833-0523 a day... Process, please refer to the radiology services section of the Provider manual for complete details )... Wheelchair items ( components ) regardless of cost per item View your benefits Participant handbook a! Blue Shield Association enrollment in Keystone First - hospital Introduction Letter Keystone First Provider,...

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