In Florida and Minnesota, it is approved as a group Medicare Supplement . The Prior Authorization Request Form is for use with the following service types: You can reach the Behavioral Health Services at 1.877.221.9295 (24 hours a day) or email behavioralhealthdocuments@healthplan.org with any questions. Superior covers prescription medications as required by the Texas Vendor Drug Program (VDP). In the event of any disagreement between this communication and the plan document, the plan document will control. Prior authorization is a requirement that a health care provider obtain approval from Medicare to provide a given service. A listing of the Medicaid, CHIP and Medicare services that require prior authorization may be accessed by visiting: CHIP pre-authorization approval and denial rates for the medical care or health-care services may be accessed by visiting: To review the Medicaid prior authorization annual review report, please reference: To access Prior Authorization Request forms for applicable services, visit Superiors Provider Forms webpage. Do not include sensitive information, such as Social Security or bank account numbers. LOG OFF IMMEDIATELY if you do not agree to the conditions stated in this warning. Autism Applied Behavioral Analysis Provider Orientation (PDF), Autism Benefit Services Initial/Continued Treatment Plan Template (PDF), Autism Benefit Services Request for Initial Evaluation (PDF), NIA: Interventional Pain Management Quick Reference Guide (QRG) (PDF), NIA: Interventional Pain Management Frequently Asked Questions (FAQ) (PDF), NIA: High Tech Imaging QRG for Rendering Facilities (PDF), NIA: High Tech Imaging QRG for Ordering Physicians (PDF), NIA: Genetic and Molecular Testing Frequently Asked Questions (FAQ) (PDF), NIA: Genetic and Molecular Testing Quick Reference Guide (QRG) (PDF), NIA: Physical Medicine (Therapy) Quick Reference Guide (QRG), NIA: Physical Medicine (Therapy) Frequently Asked Questions (FAQ), Superiors Clinical Prior Authorization webpage, Outpatient Rehabilitative and Habilitative Physical, Occupational, and Speech Therapy Services*, Behavioral Health Inpatient Authorizations (Medicaid), Behavioral Health Inpatient Authorizations (Allwell), Behavioral Health Inpatient Authorizations (Ambetter). NOTE:Most services rendered by non-participating providers require authorization. Prior Authorization. Medicaid/MyCare Authorization Form - Community Behavioral Health: Prior Authorization Code Lists. If you need help understanding the language being spoken, Superior has people who can help you on the phone or can go with you to a medical appointment. During October through March, we are available 7 days a week from 8am to 8pm. The written or verbal notice containing the details of the incomplete/insufficient clinical documentation is delivered to the provider via fax or phone, within three (3) business days after receipt of a prior authorization request containing all essential information. If you believe Wordfence should be allowing you access to this site, please let them know using the steps below so they can investigate why this is happening. Call HealthSun Health Plans at 1-877-336-2069 (TTY 1-877-206-0500). Providers should include a completed Authorization Request form and all required documentation and clinical information with an authorization request submitted through Fax. The prior authorization process is in place to assure iCare members receive the appropriate level of care and to mitigate potential fraud, waste, and abuse. If you require a prior authorization for a medication not listed here, please contact UPMC Health Plan Pharmacy Services at 1-800-979-UPMC (8762). CIGNA Healthspring Prior Authorization Form. MGJkYWY4ZjNhZDExOWQ5OTE0MjRiYzc1ZTNmNTUyN2IwMTZhMWUwZDllNDcz Inpatient Medicare Authorization Fax Form (PDF) Outpatient Medicare Authorization Fax Form (PDF) Medicare Prior Authorization List - Effective January 1, 2022 (PDF) Medicare Prior Authorization List - Effective July 1, 2022 (PDF) Medicare Prior Authorization List - Effective October 1, 2022 (PDF) Helpful Medicare Links You can reach the Behavioral Health Services at 1.877.221.9295 (24 hours a day) or email behavioralhealthdocuments@healthplan.org with any questions. Our office will be closed on Federal Holidays, Thanksgiving, and Christmas. YWMxMzA0MTU0NzMzZGViNjY1YTFmZjlhZDJlMGEzMzQzMGEzMmNiYWI1Yjc4 Medicare Part A Prior Authorization NDljMWY5MWY3NDczZTczNThiOTUzNjY0ZGQwZjQwNGQ3NWI1ZTlhMzdjN2E3 Should you need to file a complaint with Medicare you may do so by calling CMS at 1-800-Medicare. Prior authorization decisions for outpatient prescription benefits are finalized, and notification of the determination to the prescribing provider completed within twenty-four (24) hours of receipt of the request. You can also call 1-866-610-2774 for help. ZGVhMzA3NGJiMjQxZTFiYTg2OTBkZDg3YjQ3ZGE3NWZkMzY0NGNkNTI0OGY3 For Medicaid to reimburse the provider in this situation, MDHHS requires that the provider obtain authorization for these services before the service is rendered. Conveniently submit requests at the point of care through the patient's electronic health record. N2UyYTNlNTI5Yzk5NTQ0MTcxYzEyNDI5ZGQ0NjcwOTg5OWU1OTU0YTYxOGM4 Massachusetts Standard Prior Authorization forms. File your complaint online via CMS by submitting the Medicare Complaint Form. Some plans may also charge a one-time, non-refundable enrollment fee. View plan provisions or check with your sales representative. Some page levels are currently hidden. MWJmMDI4NzQ3YmQ3YjI1MWMwOTA4MTM5M2MzMTA2ZTI2MzJlNWMzOWJlMjI3 To begin the prior authorization process, providers may submit prior authorization requests to Medica Care Management by: Calling 1-800-458-5512. Top-requested sites to log in to services provided by the state, PA information for MassHealth providers for both pharmacy and nonpharmacy services. 1831 Chestnut Street St. Louis, MO 63103-2225 www.healthlink.com 1-877-284-0101 Administrative Manual Utilization Management Chapter 7 3. Some medications may require prior authorization, and may have clinical prior authorization edits or other limitations consistent with FDA recommendation for safe and effective use. The PA tab allows Fee for Service providers to submit single PA requests through the online web portal. Providers are required to appeal the denied claim(s) in this situation. Step 1 - Enter the name, phone number, and fax number of the member's plan. You can find these forms by selecting "Providers" from the navigation bar on this page, then selecting "Forms" from the "Medicare" sub-menu. If the required information is not received as required in the request, the prior authorization request is forwarded to a Medical Director for determination, based on the clinical information available. Email: Grievances&Appeals@healthsun.com Please submit this appeal form with the required documentation electronically or by mail to the information below: HealthSun Health Plans Attention: Appeals Department 9250 we Flagler St. Suite # 600 Miami, FL 33174 Fax number: (877)589-3256 Email: Grievances@Appeals@healthsun.com Sun Health HEALTH PLANS ZGVhMTUxOWFhNDY2ZWViMjNkYjg3MzZhMjBiMGYzY2Y5YzM2YzgxMzM4MzU0 You can report suspected fraud or any other non-compliance activity by calling our Member Services Department at 877-336-2069 or TTY at 877-206-0500. Optima Health Medicaid and Medicare Advantage plans include: Optima Family Care, Optima Health Community Care, Optima Medicare Value (HMO), Optima Medicare Prime (HMO), Optima Medicare Salute (HMO), and Optima Community Complete (HMO D-SNP) Check prior authorization requirements, submit new medical prior authorizations and inpatient admission notifications, check the status of a request, and submit case updates for specialties including oncology, radiology, genetic molecular testing and more. Prior Authorization: requires you HealthSun to get prior or your physician authorization for certain drugs. File your complaint online via CMS by submitting the Medicare Complaint Form. For some services, clinical review and prior authorization approval is required before the service is delivered. Provider Forms & Guides. Member Services Toll Free. It only takes a few moments tosign up for an accountand start benefitting from the many useful features provided. Plans, Inc., please provide the authorization number with your submission. The member/patient receives a written notice of the request for submission of the incomplete clinical information. All services or procedures are subject to benefit coverage, limitations and exclusions as described in applicable plan coverage guidelines. Providers may also receive a phone call requesting missing clinical information, as necessary and appropriate. Prior Authorization for MassHealth Providers. Use this button to show and access all levels. M2QzNWM1MzZjZTUxNmViZGFjNjY1YmJmMTcxOGIwYjYyY2ZlNmJlZWI4YmY3 As a provider outside of Michigan who is not contracted with us, you should submit Medicare authorization requests via fax, using the proper prior authorization form. You, your representative, or your network Primary Care Provider (PCP), or the provider that furnishes or intends . Superior HealthPlan is responsible for ensuring the medical necessity and appropriateness of all health-care services for enrolled members. ODFlOGYzM2M1Y2UwY2Y5Mzk1OWQ4MTZiOGQ3ZjlmZTAzMTI4Njk1Mjc5NjUy Prior Authorization Forms and Policies. A., and includes all elements below. The following data will be required: Authorization requests that are emergent or urgent should be submitted via telephone. You can also call 1-866-610-2774 for help. Main Office. The documents below list services and medications for which preauthorization may be required for patients with Medicaid, Medicare Advantage, dual Medicare-Medicaid and commercial coverage. We provide quality coverage from an extensive network of doctors and specialists, all backed by benefits that put you first. Authorization requirements are available in the Quick Reference Guide (QRG). Fax requests: Complete the applicable form below and fax it to 1-855-681-8650. Should you need to file a complaint with Medicare you may do so by calling CMS at 1-800-Medicare. NTk1NWQ2MGVjZDM3YzJmZmZhMTNjNzQ4YzEwYTlmMDVmMzc4YTRhMTA5ZWQy WellCare may grant multiple visits under one authorization when a plan of care shows medical necessity for this request. To review additional NIA resources, please visit theNIA Superior HealthPlan webpage. It is very important that the NPI and TIN supplied for the authorization request is the same NPI and TIN that will be included on the claim. This page includes important information for MassHealth providers about prior authorizations. To ensure that prior authorizations are reviewed promptly, submit request with current clinical notes and relevant lab work. ZTEyMjA1MWFhMjU4MWJiMzM0ZGU5Mjc3ODBlM2E5NjJlYzJiMDlkODUwYTJk HealthSun Health Plans is the five-star Medicare Advantage Plan that is consistently by your side. The provider portal includes notation of required fields for submission of all necessary information for a complete authorization request. Individual applications are subject to eligibility requirements. It is the responsibility of the rendering, ordering or referring practitioner to initiate the request for prior authorization for non-contracted provider health care services. Providers must supply the requested clinical information/documentation within three (3) business days after the request. YzMwMmMzMjgyYTU2NjZkMDUzNzcxMGVmN2Q3OGJjNmRkMTMxMmUzODRlMzk2 Simplylog inand follow these instructions. A .mass.gov website belongs to an official government organization in Massachusetts. For a full listing of prior authorization requirements, please visit the following links: Medicaid (STAR, STAR+PLUS, STAR Kids and STAR Health), 2 business days approval File your complaint online via CMS by submitting the Medicare Complaint Form. The deficiency in the PA request is communicated to the provider with the request for resubmission of the PA request. Medicare Part D. Phone: 1-855-344-0930. Michigan Prior Authorization Request Form for Prescription Drugs; Prescription determination request form for Medicare Part D; For HAP Empowered Medicaid requests, please FAX the following form to (313) 664-5460. Request for Prior Authorization Form - Medicaid; For Medical Infusible Medication requests, FAX to (313) 664-5338. Medical Management provides notice of the determination of approval or denial of the prior authorization request within three business days after receipt of a complete prior authorization request. Prior Authorization Lists. Complete this form to request a formulary exception, tiering exception, prior authorization or reimbursement. Providers who do not currently have access to the Secure Provider Portal for authorization submissions can create an account by visiting, Providers who require training on the appropriate procedures for authorization request entry through the provider portal should contact their, The link to the appropriate web portal for submission of applicable authorization requests are included under the. New Mexico Uniform Prior Authorization form (PDF) Ohio Electronic Funds Transfer (EFT) Opt Out request (PDF) Texas Standard Prior Authorization, Health Care Services request (PDF) Prior authorization is required for all elective inpatient admissions. If a prior authorization request does not include the demographic and/or clinical information necessary to complete the medical necessity review of the request, two (2) phone call attempts are completed to obtain the missing documentation/information. In addition, an electronic tool is available on Superiors website that provides procedure code specific information for the services, supplies, equipment and Clinician Administered Drugs (CAD) that require prior authorization. Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information . Notification of non-elective inpatient admissions is required no later than the close of the next business day. Superior HealthPlan is responsible for ensuring the medical necessity and appropriateness of all health-care services for enrolled members. Prior Authorization Requirements. Chiropractic Authorization: Direct all authorization questions to UCare's delegate, Fulcrum Health, Inc. | 1-877-886-4941 (toll . The requested clinical should be faxed to Medical Management, using the appropriate fax number for the service for which authorization is requested. Fax: 1-855-633-7673. Authorization phone assistance is available on weekdays from 8am 5pm in all time zones in Texas. Prior Authorization (PA) Code List - Effective 10/1/2022 : . This communication provides a general description of certain identified insurance or non-insurance benefits provided under one or more of our health benefit plans. Forms & Documents - Your South Florida Medicare Provider Health (Just Now) 2023 Personal Medication List Form; 2023 Prior Authorization Criteria - updated 09/29/2022; 2023 Step Therapy Criteria - updated 09/29/2022; HealthSun Health Plans is an HMO plan YjMxYTNjNTYyOTBlYWZmYmM3ZjU4NTc0YzE0NTc5NjgzYTVjYWJmOGU0ZmM4 Prior Authorization Forms for Medicaid and Medicare Advantage Plans. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). For more information, please contact our Member Engagement Center at 1-888-762-8633 to get started on your journey to embrace better health. Our hours of operation are Monday through Friday, 8am to 8pm. Simply call Superior Member Services. Complete the appropriate WellCare notification or authorization form for Medicare. Puerto Rico prior authorization. Plans, products, and services are solely and only provided by one or more Humana Entities specified on the plan, product, or service contract, not Humana Inc. Not all plans, products, and services are available in each state. Prior Authorization Submission. Download the free version of Adobe Reader. You can find these forms by selecting Providers from the navigation bar on this page, then selecting Forms from the Medicare sub-menu. Prior Authorization Request Contact Information. ZDY3MjhlMTNjZTZjOTQ3YThjYjZiZTEwYjgwNWJjZjVlNzIzZWM0Y2IxNTg2 ZTFkY2Y0OTNjMGRhNzgxZTA3ZDY4OTMzOTcwMDQ0NmY5OTEwYjRhOGRmMDcw Facility providers should reference theNotification of Admission and Concurrent Reviewsection on this webpage for additional details and information. REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: 9250 W Flagler St, Suite 600 Miami, FL 33174 Attention: Part D Department . To see resources for services above, please see PRIOR AUTHORIZATION RESOURCES section below. A. For Arizona residents: Insured by Humana Insurance Company. Direct Duals and State Public Program authorization submissions to UCare's delegate, Fulcrum Health, Inc., | Fax: 763-204-8572 Fulcrum Licensed Acupuncture Policy Medicaid Acupuncture Prior Authorization Request Form. Medical Prior Authorization Form English. 305-234-9292. Step 1 - Download the fillable form in Adobe PDF and open it up on the PDF reader of your choice. Prior Authorization. May 1, 2022, Humana Healthy Horizons in South Carolina (Medicaid) Preauthorization and Notification List Feb. 1, 2022, Humana Healthy Horizons in Florida (Medicaid) Preauthorization and Notification List Jan. 1, 2022, Medicare and Dual Medicare-Medicaid Plans Preauthorization and Notification List We will be doing the same soon for our other preauthorization lists. MzdhODc1YWJjYTRiNzFhNDU1NDU4ZjdmNGI5NzkzMWVlNTg3MjhiYTJhMTIw Statements in languages other than English contained in the advertisement do not necessarily reflect the exact contents of the policy written in English, because of possible linguistic differences. File your complaint online via CMS by submitting the Medicare Complaint Form. MassHealth Guidelines for Medical Necessity Determination Prior Authorization for Non-Pharmaceutical Services - Frequently Asked Questions Medical Necessity Review Forms MassHealth Drug List Prior Authorization Forms for Pharmacy Services . Fax the completed form(s) and any supporting documentation to the fax number listed on the form. Prior Authorization for Medical Services. Healthcare Shopping Tools Available The Department of Management Services offers all state employees a healthcare shopping tool called Healthcare Bluebook and a bundled service benefit for surgery, offered . Humana group medical plans are offered by Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # 00235-0008, Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc., or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, Humana Insurance of Puerto Rico, Inc. License # 00187-0009, or administered by Humana Insurance Company or Humana Health Plan, Inc. For Arizona residents, plans are offered by Humana Health Plan, Inc. or insured by Humana Insurance Company. Please reference the sections below for additional prior authorization requirements and information. Requesting providers must initiate a request for prior authorization for non-urgent health-care services prior to delivering the requested service, medical supply equipment or clinician administered drug. You may also ask us for a coverage determination by phone at (877) 336-2069. Who May Make a Request: Optima Health is the trade name of Optima Health Plan, Optima Health Insurance Company, and Sentara Health Plans, Inc. Optima Health Maintenance Organization (HMO) products, and Point-of-Service (POS) products, are issued . Louisiana Healthcare Connections providers are contractually prohibited from holding any member financially liable for any service administratively denied by Louisiana Healthcare Connections for the failure of the provider to obtain . During October through March, we are available 7 days a week from 8am to 8pm. Prior authorization is required before the provision of all non-emergent health-care services, supplies, equipment and Clinician Administered Drugs (CAD) delivered by a provider that is not contracted with Superior. In the event of a dispute, the policy as written in English is considered the controlling authority. Supplemental retiree medical coverage. We are currently in the process of enhancing this forms library. Medicare Advantage Prior Authorization Request - Prominence Health Plan. Share sensitive information only on official, secure websites. Under Prior Authorization, benefits are only paid if the medical care has been pre-approved by Medicare. As a result, you may receive our fax response before seeing the determination online. MGE2ZjU4YjY4MzdjOTk5MDgxNzUwMWNiOTMyNjgzYTQ1ODNmYmE1NGMzZTI2 It is recommended that prior authorization requests be submitted a minimum offive (5) business daysbefore the desired start date of service. Prior Authorization. Prescription Prior Authorization Form. Step 1 - Enter today's date at the top of the page. Before applying for group coverage, please refer to the pre-enrollment disclosures for a description of plan provisions which may exclude, limit, reduce, modify or terminate your coverage. NTE0NWY3ZGNjMjQ1Yjk5MThkODcyMmMzZmY1OGVhNzY0ZjY5ZjBmYmJiYjA0 Prior Authorization is about cost-savings, not care. A reasonable opportunity for physician peer discussion (Peer to Peer)is offered prior to adverse determination on all prior authorization requests, including all urgent, standard, and Medicaid incomplete prior authorization requests. Your access to this site was blocked by Wordfence, a security provider, who protects sites from malicious activity. MmQyZmY0M2M2OWE5OWFjMmVmY2IzN2FkMTM0NjFkOWY0ZTEzMDcxZDc3YTdl You can report suspected fraud or any other non-compliance activity by calling our Member Services Department at 877-336-2069 or TTY at 877-206-0500. A minimum one-year, initial contract period may be required for some dental and vision plans, excluding Dental Savings Plus. PreCheck MyScript Y2Q5ZDBkYjNlNGY1ZTQyMTZjN2E0YjBjM2JiYTlhMzk2NTIyNzQ4NDJiNDBh How to Write. An official website of the Commonwealth of Massachusetts, This page, Prior Authorization for MassHealth Providers, is, Request prior authorization for nonpharmacy services, Request prior authorization for Personal Care Attendant (PCA) Services, MassHealth Guidelines for Medical Necessity Determination, Prior Authorization for Non-Pharmaceutical Services - Frequently Asked Questions, Prior Authorization Forms for Pharmacy Services. 4. Please include ALL pertinent clinical information with your Medical or Pharmacy Prior Authorization request submission. For information on how to submit a preauthorization for frequently requested services/procedures for your patients with Humana commercial or Medicare coverage, please use the drop-down function below. Those requests will be reviewed to determine the medical necessity of approving the delivery of care outside of Superiors contracted provider network, for those situations in which no contracted provider is available to deliver the applicable service. Prior authorization requests are rejected/returned back to the provider for resubmission, if one or more essential information elements are missing, invalid or illegible. Prior authorization requests can be submitted by phone, fax or online through the Secure Provider Portal. Should you need to file a complaint with Medicare you may do so by calling CMS at 1-800-Medicare. The following guidelines are utilized to make medical necessity decisions, on a case-by-case basis, based on the information provided on the members health status, as applicable: Texas Medicaid Provider Procedures Manual (Medicaid), To access clinical policy screening criteria for specific service types, visit Superiors. MzI2M2IzZmQ0MjVhNjQwMTFhMmNjZmFjNTVmMDE3YTA0M2ZhY2U4ZjUxOWJj Your feedback will not receive a response. All essential information must be included on each PA request. A lock icon ( Our health benefit plans have exclusions and limitations and terms under which the coverage may be continued in force or discontinued. NzEyZmNjMzlkYjdhYzVmODRhOTM2Y2RmYThhMzAzNzJmZGU1MzQ2MDFkYWNm Member name, Medicaid ID number and date of birth, Requesting and rendering/servicing provider name, National Provider Identifier (NPI), and Tax Identification Number (TIN), Service requested - Current Procedural Terminology (CPT), Healthcare Common Procedure (HCPCS). To ensure that the medical necessity review of a prior authorization request can be timely processed for determination, the following information must be included with each prior authorization request: Member information (Member name, Member DOB, Member Medicaid or CHIP ID number); and, Provider information (Rendering provider name, NPI, TIN; and, Specification and description of service, supply, equipment, or CAD procedural/service code(s) and description (CPT, HCPC, NDC); and, Pertinent diagnosis/conditions that relate to the need for the service (ICD-10); and, Objective clinical information necessary to support medical necessity for the requested service; and. A listing of the Medicaid, CHIP and Medicare services that . Failure to obtain the necessary prior authorization from WellCare could result in a denied claim. There are two ways to submit an authorization via the secure Provider Portal.

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