Prior Authorization for MassHealth Providers. To ask a question or submit your precertification request, please use the following contact information: Phone: 1-877-207-4900 Fax: 305-448-4148 E-mail: utilization_dept@healthsun.com Member Information Name: Member ID: Phone: DOB: 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). MWNmNTdmZDRhYjUzY2NiNmQzZTUwMWNkMDJiNWYyM2YyYmU3OGVlZDY0ZjM2 Faxing 952-992-3556 or 952-992-3554. We will be doing the same soon for our other preauthorization lists. 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 . Contains key phone numbers and information on claims, appeals and more. Prior Authorization. Select . Simplylog inand follow these instructions. Easily find and download forms, guides, and other related documentation that you need to do business with Anthem all in one convenient location! FAX (858)790-7100. ePA submission. Providers must supply the requested clinical information/documentation within three (3) business days after the request. Step 1 - At the top of the Global Prescription Drug Prior Authorization Request Form, you will need to provide the name, phone number, and fax number for the "Plan/Medical Group Name.". All essential information must be included on each PA request. OGNiNTJmYmQ0ZGY5ZWQyZmUxYjY3NjYzNTA1ZTA2MTNiZDljN2IwNGE4NmIz 1831 Chestnut Street St. Louis, MO 63103-2225 www.healthlink.com 1-877-284-0101 Administrative Manual Utilization Management Chapter 7 Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified. Clinical screening criteria are used for the review of medical necessity of the requested service. Humana group life plans are offered by Humana Insurance Company or Humana Insurance Company of Kentucky. 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. Fax Number: (844) 430-1705 . Hours: 8 a.m. to 6 p.m. local time, Monday through Friday. Our hours of operation are Monday through Friday, 8am to 8pm. To ensure that prior authorizations are reviewed promptly, submit request with current clinical notes and relevant lab work. 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. Medical Prior Authorization Form English. Ohio Urine Drug Screen Prior Authorization (PA) Request Form: PAC Provider Intake Form: PRAF 2.0 and other Pregnancy-Related Forms: Providers may also receive a phone call requesting missing clinical information, as necessary and appropriate. During this time, you can still find all forms and guides on our legacy site. Authorization does not guarantee payment. 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 . Main Office. Plans, Inc., please provide the authorization number with your submission. MDE1NzlhNjE3ODZiYTljOTU2NjVhOTBhM2Q1YTc4ZWQ2YjllMTI1MWFmZTc5 Coming Soon Lists Effective April 1, 2023, April 1, 2023, Medicare and Dual Medicare-Medicaid Plans Preauthorization and Notification List, April 1, 2023, Commercial Preauthorization and Notification List, Coming Soon Lists Effective February 1, 2023, February 1, 2023 Humana Healthy Horizons in Kentucky (Medicaid) Preauthorization and Notification List, PDF, Coming Soon Lists Effective January 1, 2023, January 1, 2023, Humana Healthy Horizons in Florida (Medicaid) Preauthorization and Notification List, PDF, January 1, 2023, Humana Healthy Horizons in Louisiana (Medicaid) Preauthorization and Notification List, PDF, January 1, 2023, Humana Healthy Horizons in South Carolina (Medicaid) Preauthorization and Notification List, PDF, Jan. 1, 2023, Humana Gold Plus Integrated Illinois Dual Medicare-Medicaid Plan Preauthorization and Notification List, Jan. 1, 2023, Medicare and Dual Medicare-Medicaid Plans Preauthorization and Notification List, PDF, Jan. 1, 2023, Commercial Preauthorization and Notification List, PDF, Jan. 1, 2023, Part B Step Therapy Preferred Drug List, PDF, Coming Soon Lists Effective December 1, 2022, December 1, 2022 Humana Healthy Horizons in Ohio (Medicaid) Preauthorization and Notification List , PDF, October 1, 2022, Humana Healthy Horizons in Kentucky (Medicaid) Preauthorization and Notification List, PDF, August 1, 2022, Medicare and Dual Medicare-Medicaid Plans Preauthorization and Notification List, PDF, August 1, 2022, Commercial Preauthorization and Notification List, PDF, May 1, 2022, Humana Healthy Horizons in South Carolina (Medicaid) Preauthorization and Notification List, PDF, Feb. 1, 2022, Humana Healthy Horizons in Florida (Medicaid) Preauthorization and Notification List, PDF, Jan. 1, 2022, Part B Step Therapy Preferred Drug List, PDF, September 1, 2022, Humana Healthy Horizons in Kentucky (Medicaid) Preauthorization and Notification List, PDF, Feb. 1, 2022, Humana Healthy Horizons in Kentucky (Medicaid) Preauthorization and Notification List , PDF, Feb. 1, 2022, Humana Healthy Horizons in South Carolina (Medicaid) Preauthorization and Notification List, PDF, Jan. 1, 2022, Medicare and Dual Medicare-Medicaid Plans Preauthorization and Notification List, PDF, Jan. 1, 2022, Commercial Preauthorization and Notification List, PDF, Oct. 1, 2021, Humana Healthy Horizons in Kentucky (Medicaid) Preauthorization and Notification List , PDF, Aug. 1, 2021, Humana Healthy Horizons in Florida (Medicaid) Preauthorization and Notification List, PDF, July 1, 2021, Humana Healthy Horizons in South Carolina (Medicaid) Preauthorization and Notification List, PDF, Jan. 1, 2021, Commercial Preauthorization and Notification List , PDF, Jan. 1, 2021, Medicare and Dual Medicare-Medicaid Plans Preauthorization and Notification List, PDF, Jan. 1, 2021, Part B Step Therapy Preferred Drug List, PDF, Jan. 1, 2020, Commercial Preauthorization and Notification List, PDF, Jan. 1, 2020, Medicare and Dual Medicare-Medicaid Plans Preauthorization and Notification List, PDF, Jan. 1, 2020, Part B Step Therapy Preferred Drug List, PDF, Jan. 1, 2020, Kentucky Medicaid Preauthorization and Notification List, PDF, Specific medical and pharmacy coverage criteria and updates, Medical coverage criteria updates and recent changes, PDF, How to register for the Availity Portal, PDF, Streamline preauthorizations and referrals, PDF, Indiana preauthorization request form, PDF, New Mexico preauthorization request form, PDF, State-specific preauthorization statistics, Colorado preauthorization statistics medical, Colorado preauthorization statistics pharmacy, Georgia preauthorization statistics medical, Georgia preauthorization statistics pharmacy, Illinois preauthorization statistics medical, Illinois preauthorization statistics pharmacy, Texas preauthorization statistics medical, Texas preauthorization statistics pharmacy. Medicaid/MyCare Authorization Form - Community Behavioral Health: Prior Authorization Code Lists. MzdhODc1YWJjYTRiNzFhNDU1NDU4ZjdmNGI5NzkzMWVlNTg3MjhiYTJhMTIw The member/patient receives a written notice of the request for submission of the incomplete clinical information. LOG OFF IMMEDIATELY if you do not agree to the conditions stated in this warning. View plan provisions or check with your sales representative. Superior does not financially incentivize physicians or other individuals in utilization review decision making, and Superior utilization management policy and criteria do not encourage decisions that result in underutilization. Download the free version of Adobe Reader. NOTE:Most services rendered by non-participating providers require authorization. Provider Services. YzMwMmMzMjgyYTU2NjZkMDUzNzcxMGVmN2Q3OGJjNmRkMTMxMmUzODRlMzk2 Approval or denial of prior authorization requests received by phone will be finalized immediately, during the call. Authorization phone assistance is available on weekdays from 8am 5pm in all time zones in Texas. Under Prior Authorization, benefits are only paid if the medical care has been pre-approved by Medicare. NzBjNjY1ZDhlMGFkZjk3NDA4MzUwMDMzOWUwMGM3MTVjOGZlMzA3ZWVjODY5 . MGJkYWY4ZjNhZDExOWQ5OTE0MjRiYzc1ZTNmNTUyN2IwMTZhMWUwZDllNDcz Please reference the sections below for additional prior authorization requirements and information. -----END REPORT-----. 877-336-2069. Prior Authorization. This page includes important information for MassHealth providers about prior authorizations. MGE2ZjU4YjY4MzdjOTk5MDgxNzUwMWNiOTMyNjgzYTQ1ODNmYmE1NGMzZTI2 Prior Authorization. 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. Top-requested sites to log in to services provided by the state, PA information for MassHealth providers for both pharmacy and nonpharmacy services. YWMxMzA0MTU0NzMzZGViNjY1YTFmZjlhZDJlMGEzMzQzMGEzMmNiYWI1Yjc4 Some plans may also charge a one-time, non-refundable enrollment fee. 3 business days denial, Medicaid (STAR, STAR+PLUS, STAR Kids and STAR Health), CHIP. YWI5YWI3NDlmODk2NWQ1YjE2YzU0YWEyZDUzYTQ4OTkxMTZhMWEyYzA3OGQ2 Fax the completed form (s) and any supporting documentation to the fax number listed on the form. The forms below cover requests for exceptions, prior authorizations and appeals. 2022 Prior Authorization Criteria - updated 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. You may also ask us for a coverage determination by phone at (877) 336-2069. Who May Make a Request: Fax requests for treatment to 1.866.616.6255. Please note: We are currently changing the layout of our lists to allow for easier searching. In all states but Florida and Minnesota, it is offered as a supplementary medical plan, not a Medicare plan. Prior authorization and/or a referral may apply. 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 . MWJmMDI4NzQ3YmQ3YjI1MWMwOTA4MTM5M2MzMTA2ZTI2MzJlNWMzOWJlMjI3 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. Prior authorization means your doctor must get approval before providing a service or prescribing a medication. Humana group dental plans are offered by Humana Insurance Company, HumanaDental Insurance Company, Humana Insurance Company of New York, The Dental Concern, Inc., Humana Medical Plan of Utah, Humana Health Benefit Plan of Louisiana, Inc., CompBenefits Company, CompBenefits Insurance Company, CompBenefits Dental, Inc., Humana Employers Health Plan of Georgia, Inc., or DentiCare, Inc. (DBA CompBenefits). MzQzOWRiMjgwNjg0OTFiOGQ4MDUyYTMzYzI4Njk3ODViMGZlZTJkYTBjY2I2 Should you need to file a complaint with Medicare you may do so by calling CMS at 1-800-Medicare. Humana legal entities that offer, underwrite, administer or insure insurance products and services. Providers MmQyZmY0M2M2OWE5OWFjMmVmY2IzN2FkMTM0NjFkOWY0ZTEzMDcxZDc3YTdl Share sensitive information only on official, secure websites. Wellcare uses cookies. 3. Prior Authorization for Medical Services. Forms & Documents - Your South Florida Medicare Provider Health (Just Now) 2022 Personal Medication List Form. Complete the appropriate WellCare notification or authorization form for Medicare. Prescription Prior Authorization Form. Surescripts Prior Authorizatio Portal. Providers are encouraged to utilize the Secure Provider Portal for electronic submission of authorization requests. NTVjYTk1MzhjZjZiYTY3OTM5NDg0YTkxYTI5ZTc1M2EyZmViOWEwOTBkMzY4 The PA tab allows Fee for Service providers to submit single PA requests through the online web portal. Clinical Policy and Screening Criteria webpage. Use this button to show and access all levels. 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) ZTFkY2Y0OTNjMGRhNzgxZTA3ZDY4OTMzOTcwMDQ0NmY5OTEwYjRhOGRmMDcw Standard Prior Authorization Request - Incomplete or Insufficient Documentation. Go365 is not an insurance product. Supplemental retiree medical coverage. Failure to notify within the timeframe required will result in a late notification denial, unless otherwise stated within a Superior contract. Authorization phone requests require subsequent submission of applicable documentation and clinical information to facilitate the medical necessity review of the request. In an increasingly complex health care environment, iCare is committed to offering solutions that help health care professionals save time and serve their patients. Please consult the QRG for details. Massachusetts Standard Prior Authorization forms. If you have purchased an association plan, an association fee may also apply. For notification of inpatient admission by service area throughout the state of Texas for all Medicaid and CHIP programs, please reference the phone and fax numbers below: Concurrent utilization review to determine the medical necessity for inpatient days for a hospitalized patient is completed within one (1) business day of receipt. Should you need to file a complaint with Medicare you may do so by calling CMS at 1-800-Medicare. ZTEyMjA1MWFhMjU4MWJiMzM0ZGU5Mjc3ODBlM2E5NjJlYzJiMDlkODUwYTJk Meaning, you should contact your plan directly to confirm coverage. Prior Authorization Request Contact Information. 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 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. Requests for expedited authorization will receive a determination within three business days. Should you need to file a complaint with Medicare you may do so by calling CMS at 1-800-Medicare. Prior authorization requests are rejected/returned back to the provider for resubmission, if one or more essential information elements are missing, invalid or illegible. If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request. Refer to the Pharmacy section of the website for information regarding prescription authorization requirements. NmEwMWZhN2U3MTIyNDQxNDRmOWEyNzg2OWE4N2RlNjA5MDBkZDhhNGU0YjE0 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. 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. There are two ways to submit an authorization via the secure Provider Portal. Prior Authorization Request Form. NDljMWY5MWY3NDczZTczNThiOTUzNjY0ZGQwZjQwNGQ3NWI1ZTlhMzdjN2E3 File your complaint online via CMS by submitting the Medicare Complaint Form. If the medical necessity of a prior authorization cannot be confirmed by clinical staff, a Texas licensed physician/medical director reviews the case, and includes the opportunity for a peer discussion with the rendering/ordering provider prior to issuing any adverse determination. File your complaint online via CMS by submitting the Medicare Complaint Form. Medicare Part A Prior Authorization NzEyZmNjMzlkYjdhYzVmODRhOTM2Y2RmYThhMzAzNzJmZGU1MzQ2MDFkYWNm Include the patient's full name, member ID, address, phone number, DOB, allergies, primary insurance, policy number, and group number. Administered by Humana Insurance Company. Now, when it comes to Medicare Advantage and Medicare Part D, coverage is often plan-specific. 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 If the EMR/EHR does not support ePA, you can use one of these vendor portals: CoverMyMeds ePA portal. In states, and for products where applicable, the premium may include a $1 administrative fee. We are currently in the process of enhancing this forms library. Other medically necessary pharmacy services or products are covered consistent with VDP guidance. We provide quality coverage from an extensive network of doctors and specialists, all backed by benefits that put you first. To review additional NIA resources, please visit theNIA Superior HealthPlan webpage. As a result, you may receive our fax response before seeing the determination online. For New Mexico residents: Insured by Humana Insurance Company. You can also call 1-866-610-2774 for help. Step 3 - Under "Prescriber Information", enter the physician's name, NPI number, address, phone number, fax number, and contact person. NTE0NWY3ZGNjMjQ1Yjk5MThkODcyMmMzZmY1OGVhNzY0ZjY5ZjBmYmJiYjA0 Fax the completed form(s) and any supporting documentation to the fax number listed on the form. 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. Providers should include a completed Authorization Request form and all required documentation and clinical information with an authorization request submitted through Fax. Retrospective authorizations NjY4MWU1ZWVjZjVkZmM5ZTY4ZDc4YWE2OTZhNzNmYjJlYWU0MzNhMTVmMGM3 The fastest and most efficient way to request an authorization is through our secureProvider Portal, however you may also request an authorization via fax or phone (emergent or urgent authorizations only). Step 2 - "Section A" must be completed with the patient's information. Following notification of admission, concurrent and/or retrospective utilization review is conducted to confirm the continued medical necessity of the inpatient stay. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. All services or procedures are subject to benefit coverage, limitations and exclusions as described in applicable plan coverage guidelines. If you see the below notification, it's because the UM Form Notification Form is not available during this time and you have to call to our Medical Management Department for further assistance. 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. 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 . If the clinical information/documentation is not received within the required timeframe, the case will be reviewed with the incomplete or insufficient information received with the PA request. For some services, clinical review and prior authorization approval is required before the service is delivered. Fax: 1-855-633-7673. These include non-elective, inpatient admissions, including those that are subsequent to emergency services and stabilization of the patient, which do not require prior authorization. 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. Providers must obtain prior authorization for certain services and procedures. Superior HealthPlan is responsible for ensuring the medical necessity and appropriateness of all health-care services for enrolled members. A lock icon ( Main Office Toll Free. Professional services provided during a medically necessary inpatient admission do not require separate authorization. If the provider identifiers in the authorization do not match the provider identifiers on the claim, the claim may be denied even if the authorization request was approved. Humana Individual dental and vision plans are insured or offered by Humana Insurance Company, HumanaDental Insurance Company, Humana Insurance Company of New York, The Dental Concern, Inc., CompBenefits Insurance Company, CompBenefits Company, CompBenefits Dental, Inc., Humana Employers Health Plan of Georgia, Inc. or Humana Health Benefit Plan of Louisiana, Inc. Discount plans offered by HumanaDental Insurance Company or Humana Insurance Company. Request for Prior Authorization Form - Medicaid; For Medical Infusible Medication requests, FAX to (313) 664-5338. Complete the appropriate WellCare notification or authorization form for Medicare. You, your representative, or your network Primary Care Provider (PCP), or the provider that furnishes or intends . These include the following Texas licensed Utilization Review Agents: You will need Adobe Reader to open PDFs on this site. Prior authorization is required for all elective inpatient admissions. Do not include sensitive information, such as Social Security or bank account numbers. Prior Authorization. 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. Facility providers should reference theNotification of Admission and Concurrent Reviewsection on this webpage for additional details and information. Prior Authorization Submission. Please include ALL pertinent clinical information with your Medical or Pharmacy Prior Authorization request submission. Should you need to file a complaint with Medicare you may do so by calling CMS at 1-800-Medicare. Prior Authorization is about cost-savings, not care. You can reach the Behavioral Health Services at 1.877.221.9295 (24 hours a day) or email behavioralhealthdocuments@healthplan.org with any questions. For costs and complete details of the coverage, refer to the plan document or call or write your Humana insurance agent or the company. 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. Prior Authorization (PA) Code List - Effective 10/1/2022 : . MDNmIn0= Mailing it to: Medica Care Management Route CP440 PO Box 9310 Minneapolis, MN 55440-9310 . 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 Providers are required to appeal the denied claim(s) in this situation. Health & Social Services; MassHealth; . . A minimum one-year, initial contract period may be required for some dental and vision plans, excluding Dental Savings Plus. Star Ratings Wellness Education Community Centers Providers Forms, Manuals and Resource Library Find a plan near you Enter your ZIP code to learn about the CarePlus Medicare Advantage plans in your area, or call us at 1-855-605-6171; TTY: 711. Conveniently submit requests at the point of care through the patient's electronic health record. NDg3OWNjZDRhZDRjZjg4NTRiYjAyNjc3YWUxNTJiYzM5MDk5MzJhMzNlZGVi 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. ZWE1MTNmZDY2N2VjOTBkZTMzNTEzZjY5ZTAxYjkzMDIxYTk5ODYxNDhlMDRh ZGVhMzA3NGJiMjQxZTFiYTg2OTBkZDg3YjQ3ZGE3NWZkMzY0NGNkNTI0OGY3 All inpatient confinements do require notification of the admission no later than the next business day after the date of admission. It only takes a few moments tosign up for an accountand start benefitting from the many useful features provided. Provider Forms & Guides. A. MDlkNjNhY2EyMDI2YWIzYWU1YmZlMGY4ZjcyZWY2M2IxMDFiZDcxNGI5OGRl HealthSun Health Plans is the five-star Medicare Advantage Plan that is consistently by your side. Private, for-profit plans often require Prior Authorization. Diagnostic Imaging (CT, CTA, MRI, MRA, PET), *For Medicaid STAR, CHIP and STAR+PLUS (non-STAR+PLUS HCBS Waiver) members. Applied Behavioral Analysis (ABA) Services, Diagnostic Imaging (CT, CTA, MRI, MRA, PET) and Cardiac Imaging, Outpatient Rehabilitative and Habilitative Physical, Occupational, and Speech Therapy Services (*For Medicaid STAR, CHIP and STAR+PLUS [non-STAR+PLUS HCBS Waiver] members), Medicaid prior authorization requests must contain all Essential Information. Our office will be closed on Federal Holidays, Thanksgiving, and Christmas. Our hours of operation are Monday through Friday, 8am to 8pm. 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. A Prior Authorization is a decision made by the plan regarding certain medical services that require pre-approve, prior to furnishing, arranging for, or providing for the health care service. 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. File your complaint online via CMS by submitting the Medicare Complaint Form. ZGNlYTYzNTI5NWYxZDk3NGE3NDIxYzk2YjJmNDE2Y2YxMWMyM2ZhYTkzYjc1 Prior Authorization Forms and Policies. 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. Medicare Advantage Prior Authorization Request - Prominence Health Plan. Utilization review decisions are made in accordance with generally-accepted clinical practices, taking into account the special circumstances of each case that may require an exception to the standard. Chiropractic Authorization: Direct all authorization questions to UCare's delegate, Fulcrum Health, Inc. | 1-877-886-4941 (toll . You can find these forms by selecting Providers from the navigation bar on this page, then selecting Forms from the Medicare sub-menu. You can also request any materials on this website in another format, such as large print, braille, CD or in another language. Fax the request form to 888.647.6152. This communication provides a general description of certain identified insurance or non-insurance benefits provided under one or more of our health benefit plans. Molina Healthcare/Molina Medicare Prior Authorization Request Form Phone Number: (888) 483-0760 Medicaid/CHIP Fax Number: (866) 472-0589 Medicare Fax Number: (866) 504-7262 Member Information 877-207-4900. We will use this information to improve the site. MzI2M2IzZmQ0MjVhNjQwMTFhMmNjZmFjNTVmMDE3YTA0M2ZhY2U4ZjUxOWJj Your access to this site was blocked by Wordfence, a security provider, who protects sites from malicious activity. ZDY3MjhlMTNjZTZjOTQ3YThjYjZiZTEwYjgwNWJjZjVlNzIzZWM0Y2IxNTg2 The deficiency in the PA request is communicated to the provider with the request for resubmission of the PA request. Authorization determinations are made based on medical necessity and appropriateness and reflect the application of WellCares review criteria guidelines. 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.
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