I attest that the medication requested is medically necessary for this patient. Paul, mn 55164 please refer to current pre authorization lists to verify if service requires pre authorization. If you have any questions or comments about the forms, please contact us. Prior authorizationstep therapy program this program encourages safe, cost. Prior authorization required on some medications before your drug will be covered. Prior authorization forms blue shield of california. Please ensure that this form is a direct copy from the master. This authorization cannot be used to disclose psychotherapy notes. Fax form and relevant clinical documentation to 651 6622810 or mail to. Abortion request authorization hfs form 2390 pdf sterilization consent form hfs form 2189 pdf hysterectomy information hfs form 1977 pdf hospice election form pdf master maintenance form pdf memberconnections referral form pdf memberconnections resolution form pdf disclosure of ownership and control interest statement form pdf. The prior authorization pa and step therapy st programs encourage the safe and costeffective use of medication by allowing coverage when certain conditions are met. Incomplete forms will be returned for additional information. Standard authorization form to use or disclose phi blue cross.
The prior authorization pa and step therapy st programs encourage the. Some bcbs plans have radiology management programs, other than aim. These programs may be tied to member benefits, and therefore it is important to check benefits prior to service by calling the bluecard eligibility hotline at 800676blue2583. As a result of public act 0970689 pdf, referred to as the save medicaid access and resources together smart act, the department must develop utilization controls, including prior approval, for specialty drugs, oncolytic drugs, drugs for the treatment of hiv or aids, immunosuppressant drugs, and biological products in order to maximize. In addition to commercial issuers, the following public issuers must accept the form. Prior authorization of benefits is not the practice of medicine or a substitute for the independent medical judgment of a treating physician. If you are already taking or are prescribed a drug that is part of the prior authorization program, your doctor can submit a prior authorization request form. Prior authorizationutilization management blue cross and. To view this file, you may need to install a pdf reader program. Prior authorization and step therapy programs blue cross blue. To submit a prior authorization online, please click the button below to use the web form. Effective january 1, 2014, orthonets scope of responsibility includes the management of the prior authorization process for outpatient physical therapy and chiropractic services for city of chicago employees covered by a bcbsil policy.
See reverse side for additional details once a clinical decision has been made, a decision letter will be mailed to the patient and physician. Pharmacy prior auth link added for bcbsil availity has added a bcbs pharmacy prior authorization link for blue cross and blue shield of illinois bcbsil. Care coordinationcomplex case management referral form. Call the drug prior approval hotline at 18002528942. Drug prior auth request form 1217 blue cross blue shield. Some of these documents are available as pdf files. A electronic submission allows clinical attachments to be made to the prior authorization form and allows the form to be submitted online without printing or faxing if the provider that will be rendering the service is an individual practitioner, please list the individual npi. Formulary exceptionprior authorization request form. Prior authorization request forms excellus bluecross blueshield. Prior authorizationstep therapy program blue cross blue. Free illinois medicaid prior rx authorization form pdf. This includes prior authorization for hightech imaging services. Prior authorization request submit the completed form. Emergency room inpatient 23hour observation it is the responsibility of the ordering provider to request prior authorization approval for services.
Blue cross completes prior authorization criteria for a brandname daw request. As a result of public act 0970689 pdf, referred to as the save medicaid access and resources together smart act, the department must develop utilization controls, including prior approval, for specialty drugs, oncolytic drugs, drugs for the treatment of hiv or aids, immunosuppressant drugs, and biological products in order to maximize savings on these drugs. Careplan of illinois prior authorization pa policy primary health care professionals or referring health care professionals. Important notice from blue cross and blue shield of illinois. Paul, mn 55164 please refer to current preauthorization lists to verify if service requires preauthorization. This link will take you to a new site not affiliated with bcbstx. I further attest that the information provided is accurate and true, and that documentation supporting this.
If you are already taking or are prescribed a drug that is part of the prior authorization program, your doctor can submit a prior authorization request form so your prescription can be. Blue shield of illinois bcbsil members with prescription drug coverage. If the subscriber is medicare eligible, please complete entire form. Forms and documents blue cross and blue shield of illinois. Page 1 of 2 webpnye021117 november 2017 nys medicaid prior authorization request form for prescriptions rationale for exception request or prior authorization all information must be complete and legible patient. Prior authorization for the following drugs andor therapeutic categories, the diagnosis, applicable lab data, and involvement of specialists are required, plus additional information as specified. Blue cross and blue shield of illinois bcbsil protects its members in this same way. Prior authorization is required before these drugs are administered in these locations. Request for medicaid prescription drug coverage determination. Illinois medicaid prior rx authorization form if you are interested in requesting medicaid coverage for a nonpreferred drug in the state of illinois, you will need to fill and submit an illinois medicaid prior authorization form. Blue cross complete medication prior authorization request. Prior authorization coverage determination form pdf, 6 kb nonformulary exception and quantity limit exception pdf, 129 kb tier exception pdf, 109 kb prescription drug prior authorization and step therapy exception request forms. Texas standard prior authorization request form for health.
May, 2015 to help you get a better idea of how prior authorization works we have answered some of the most popular questions from members. Available 247 and the quickest way to create prior authorizations and check existing case status. Most hmo groups and standard products plans include this program. All information below is required to process this request. If you are providing service to out of area blue cross and blue shield bcbs members, please note. Your standard authorization form a standard authorization form lets you decide how bcbsil can share your phi. I request and authorize blue cross and blue shield of illinois to disclose my protected. Antirheumatic drugs enbrel, humira, kineret forteo. Predetermination request form blue cross blue shield of illinois. Prior authorization, step therapy, formulary exception. If you are interested in requesting medicaid coverage for a nonpreferred drug in the state of illinois, you will need to fill and submit an illinois medicaid prior authorization form. Expedited preservice clinical appeal form pdf file. Selfinsured and custom fully insured groups offer a variety of these programs to help. Authorization request form this form is for authorization of prescription drug benefits only and must be completely filled out.
Expedited preservice clinical appeal form, commercial only. Prior authorization health insurance can be complicatedespecially when it comes to prior authorization also referred to as preapproval, pre authorization and precertification. General information patient name request type please check one prior authorization step therapy exception request for quantity limit exception city appeal mandatory generic exception. Illinois outpatient medicaid prior authorizationreferral. Medicaid service authorization dispute resolution request form, medicaid only bcchp and. The medicare plus blue prior authorization codes list pdf represents procedures that require authorization by evicore healthcare for medicare plus blue ppo members who reside in michigan and. Formulary exception prior authorization request form. Information contained in this form is protected health information under hipaa. Weve provided the following resources to help you understand anthem s prior authorization process and obtain authorization for your patients when its required.
Alternatively, you can call the number provided below and make your request over the phone. Prior authorization blue cross and blue shield of illinois. Nov 16, 2016 to submit a prior authorization online, please click the button below to use the web form. Health care provider forms blue cross and blue shield of. For formulary information please visit start saving time today by filling out this prior authorization form. Prior authorization step therapy program this program encourages safe, cost.
Coordination of benefitsblue cross and blue shield of alabama is host plan. The request may originate from the prescriber or from the pharmacy. If you do not have adobe reader, download it free of charge at adobes site. The prior authorization process determines whether services are medically necessary and appropriate based on clinical coverage criteria and is not a reflection of a members benefits or eligibility. Quantity limits exception form external link pdf document.
Complete and fax the appropriate prior approval request form to 8008431114. Blue cross and blue shield of illinois bcbsil is committed to providing you with the forms you need to support your business. Pdf forms are available below to submit a prior authorization through fax. If you have any ior authorization team at the number listed on the top of this form. Prior authorization forms provider blue shield of ca. If the patient is not able to meet the above standard prior authorization requirements, please call 18007114555.
Please complete and fax this request form along with all supporting clinical documentation to orthonet at 18888759481. For urgent or expedited requests please call 18007114555. Standard request determination within 10 calendar days from receipt of all necessary information. Fep prior approval lists and forms premera blue cross. Prior authorizationcoverage determination form pdf, 6 kb. Online prior authorization form pdf forms are available below to submit a prior authorization through fax. The forms in this online library are updated frequentlycheck often to ensure you are using the most current versions. The drug authorization request form may be downloaded from an insurers website. Blue cross and blue shield of illinois bcbsil prior authorization step therapy program is designed to encourage safe, costeffective medication use. If your health plans formulary guide indicates that you need a prior authorization for a specific drug, your physician must submit a prior authorization request form to the health plan for approval. Drug prior approval requests may be submitted using the following methods. Provider demographic change form please submit this form to our corporate provider file department when adding additional office locations to your practice, or if your practice moves from its current location. Effective january 1, 2014, orthonets scope of responsibility includes the management of the priorauthorization process for outpatient physical therapy and chiropractic services for city of chicago employees covered by a bcbsil policy. Outpatient elective nonemergent evicore prior authorization does not apply to services that are performed in.
Physicians must complete and submit a request form for all pa and st medications. Blue cross blue shield of texas is committed to giving health care providers with the support and assistance they need. Some drugs need to be approved by the plan before they are covered. Prior authorization is required for various services, procedures, prescription drugs, and medical devices.
The forms in this online library are updated frequently check often to ensure you are using the most current versions. Bcbs il pt request form20 59008 activated, traditional. Prior authorization health insurance can be complicatedespecially when it comes to prior authorization also referred to as preapproval, preauthorization and precertification. What prescription drugs call for prior authorization. Prior authorization is not required in an emergency room, inpatient hospital or an urgent care center. Member authorization form blue cross and blue shield of illinois. Cms 2728 form must be used for both medicare and nonmedicare subscribers. Depending upon the drug, either the prescribing physician or the dispensing pharmacist may submit the request.
Please fill out all applicable sections on both pages completely and legibly. I will let blue cross and blue shield of illinois bcbsil share the records below check only. Drugs with step therapy requirements may be covered if a prior health plan paid for the drug documentation of a paid claim may be required. All members can keep their phi safe by using a standard authorization form. Prescription drug prior authorization and step therapy exception request forms. Includes any information related to preservice, concurrent and post service. Office drugs prior authorization request pdf, 301 kb. Abortion x health care professional must submit required hfs form 2390 with the claim submission admissions x inpatient admission yes, prior authorization required. Prior authorization referral fax form complete and fax to. Downloadable forms blue cross blue shield of illinois. Beginning september 1, 2015, health benefit plan issuers must accept the texas standard prior authorization request form for health care services if the plan requires prior authorization of a health care service. Medication request form fax to 14125447546 please use separate form for each drug. Outpatient medicaid prior authorizationreferral fax form complete and fax to.
Prior authorization criteria and form external link pdf document. Print, type or write legibly and complete the form in full. Prior authorization blue cross blue shield association. Access and download these helpful bcbstx health care provider forms. The plan can ask you to start treatment with a drug that costs less but works just as well for example, a generic name drug instead of starting with a drug that costs more. Please forward a copy of the submitted medwatch form with this request. Blue cross and blue shield of illinois bcbsil offers blue cross community health plans bcchp which includes a network of independently contracted providers including physicians, hospitals, skilled nursing facilities, ancillary providers, longterm services and support ltss and other health care providers through which illinois medicaid members may. These programs may be tied to member benefits, and therefore it is important to check benefits prior to service by calling the bluecard eligibility hotline at 800 676blue2583. Massachusetts standard form for medication prior authorization requests some plans might not accept this form for medicare or medicaid requests. Medical policy manual and by medical professionals to describe services that bluecross. Meridianhealth illinois prior authorization requirements. A clinical team of physicians and pharmacists develops and approves the clinical programs and criteria by.
Use this form when requesting prior authorization of therapy services for bcbsil members. Request for redetermination of medicaid prescription drug denial. Prior authorization of sleep for blue cross and blue shield. Blue cross community mmai forms and documents blue cross. Blue cross and blue shield of minnesota and blue plus. Documentation of an adverse event or lack of efficacy with the generic formulation and completion of an fda medwatch form. Benefit prior authorization blue cross blue shield of illinois. Certain health care services and prescription drugs will need to be approved by blue cross and blue shield of illinois bcbsil before they are covered under your plan. In your request, you will be asked to provide all information. Fax completed form to 18773289799 if this an urgent request, please call 18007532851. If you are providing service to outofarea blue cross and blue shield bcbs members, please note. This form may be used for nonurgent requests and faxed to 18005270531.
If originating at the pharmacy, the pharmacy must transmit the form to the prescriber for the justification, medical information, and the prescribers or authorized representatives signature. Prior authorization, sometimes called pa or precertification, is the how blue cross makes sure the treatment your doctor prescribes is medically necessary. You must also complete any other preservice requirements, such as preauthorization, if applicable and required. Prior authorizationutilization management blue cross. This is so the plan can best guide the correct use of these drugs.
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