Forms and documents 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. Prior authorization of benefits is not the practice of medicine or a substitute for the independent medical judgment of a treating physician. 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. Prior authorization blue cross blue shield of illinois. 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. Blue cross and blue shield of minnesota and blue plus.
All information below is required to process this request. Formulary exception prior authorization request form. I will let blue cross and blue shield of illinois bcbsil share the records below check only. Prior authorizationstep therapy program this program encourages safe, cost. Documentation of an adverse event or lack of efficacy with the generic formulation and completion of an fda medwatch form.
Health care provider forms blue cross and blue shield of. If you do not have adobe reader, download it free of charge at adobes site. The prior authorization pa and step therapy st programs encourage the. Medical policy manual and by medical professionals to describe services that bluecross. Use this form when requesting prior authorization of therapy services for bcbsil members. Incomplete forms will be returned for additional information. Prior authorization is not required in an emergency room, inpatient hospital or an urgent care center. Expedited preservice clinical appeal form pdf file. Standard authorization form to use or disclose phi blue cross.
Illinois outpatient medicaid prior authorizationreferral. Information on this form is protected health information and subject to all privacy and security regulations under hipaa. Blue cross complete medication prior authorization request. Downloadable forms blue cross blue shield of illinois. Prior authorization, sometimes called pa or precertification, is the how blue cross makes sure the treatment your doctor prescribes is medically necessary. This includes prior authorization for hightech imaging services. For formulary information please visit start saving time today by filling out this prior authorization form.
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. I request and authorize blue cross and blue shield of illinois to disclose my protected. The request may originate from the prescriber or from the pharmacy. What prescription drugs call for prior authorization. Meridianhealth illinois prior authorization requirements. Anthem partners with health care professionals to close gaps in care and improve members overall heath. 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 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. Prior authorization request submit the completed form. 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. Most hmo groups and standard products plans include this program. Please complete and fax this request form along with all supporting clinical documentation to orthonet at 18888759481.
Important notice from blue cross and blue shield of illinois. Blue cross and blue shield of illinois bcbsil protects its members in this same way. I attest that the medication requested is medically necessary for this patient. Weve provided the following resources to help you understand anthem s prior authorization process and obtain authorization for your patients when its required. Prior authorization criteria and form external link pdf document. You must also complete any other preservice requirements, such as preauthorization, if applicable and required. In addition to commercial issuers, the following public issuers must accept the form. A clinical team of physicians and pharmacists develops and approves the clinical programs and criteria by. Blue shield of illinois bcbsil members with prescription drug coverage. Blue cross completes prior authorization criteria for a brandname daw request. If the subscriber is medicare eligible, please complete entire form. If the patient is not able to meet the above standard prior authorization requirements, please call 18007114555.
Call the drug prior approval hotline at 18002528942. I further attest that the information provided is accurate and true, and that documentation supporting this. Prior authorization forms blue shield of california. Request for medicaid prescription drug coverage determination. 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.
If you have any ior authorization team at the number listed on the top of this form. General information patient name request type please check one prior authorization step therapy exception request for quantity limit exception city appeal mandatory generic exception. Antirheumatic drugs enbrel, humira, kineret forteo. Prior authorization request forms excellus bluecross blueshield. Includes any information related to preservice, concurrent and post service. Benefit prior authorization blue cross blue shield of illinois. Prior authorization required on some medications before your drug will be covered. Caremark specialty enrollment form to begin the pa process for those cases. 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.
Blue cross and blue shield of illinois bcbsil prior authorization step therapy program is designed to encourage safe, costeffective medication use. 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. Some of these documents are available as pdf files. 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. Member authorization form blue cross and blue shield of illinois. 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. Drug prior auth request form 1217 blue cross blue shield. Prior authorization of sleep for blue cross and blue shield. 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. 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. Care coordinationcomplex case management referral form. Depending upon the drug, either the prescribing physician or the dispensing pharmacist may submit the request.
The forms in this online library are updated frequentlycheck often to ensure you are using the most current versions. Outpatient elective nonemergent evicore prior authorization does not apply to services that are performed in. All members can keep their phi safe by using a standard authorization form. If you have any questions or comments about the forms, please contact us.
Some drugs need to be approved by the plan before they are covered. Prior authorization referral fax form complete and fax to. Access and download these helpful bcbstx health care provider forms. Jun 01, 2019 prior authorization is not required for blue cross medicare private fee for service members, but providers or members can request it if they want. This link will take you to a new site not affiliated with bcbstx. Medication request form fax to 14125447546 please use separate form for each drug. Please ensure that this form is a direct copy from the master. Office drugs prior authorization request pdf, 301 kb.
If the first drug doesnt work for you, then the plan will cover the higherpriced drug. Massachusetts standard form for medication prior authorization requests some plans might not accept this form for medicare or medicaid requests. Prior authorization is required for various services, procedures, prescription drugs, and medical devices. Please forward a copy of the submitted medwatch form with this request. See reverse side for additional details once a clinical decision has been made, a decision letter will be mailed to the patient and physician.
Pdf forms are available below to submit a prior authorization through fax. In your request, you will be asked to provide all information. Fep prior approval lists and forms premera blue cross. Please fill out all applicable sections on both pages completely and legibly.
Careplan of illinois prior authorization pa policy primary health care professionals or referring health care professionals. Authorization request form this form is for authorization of prescription drug benefits only and must be completely filled out. Blue cross community mmai forms and documents blue cross. The forms in this online library are updated frequently check often to ensure you are using the most current versions. Blue cross and blue shield of illinois bcbsil is committed to providing you with the forms you need to support your business.
Standard request determination within 10 calendar days from receipt of all necessary information. Fax completed form to 18773289799 if this an urgent request, please call 18007532851. Prior authorizationutilization management blue cross. Physicians must complete and submit a request form for all pa and st medications. Information contained in this form is protected health information under hipaa. 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. 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.
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. How to request precertification for an admission or get prior authorization for. 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. Outpatient medicaid prior authorizationreferral fax form complete and fax to. Free illinois medicaid prior rx authorization form pdf. Prior authorization blue cross blue shield association. Request for redetermination of medicaid prescription drug denial. Cms 2728 form must be used for both medicare and nonmedicare subscribers. This authorization cannot be used to disclose psychotherapy notes.
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. This is so the plan can best guide the correct use of these drugs. To view this file, you may need to install a pdf reader program. Complete and fax the appropriate prior approval request form to 8008431114. To submit a prior authorization online, please click the button below to use the web form. General exception request form self administered drugsopen a pdf used for requests that do not have a specific form below, or may be used to request.
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. 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. Fax form and relevant clinical documentation to 651 6622810 or mail to. Prior authorization step therapy program this program encourages safe, cost. Prior authorization is required before these drugs are administered in these locations. This form may be used for nonurgent requests and faxed to 18005270531. Alternatively, you can call the number provided below and make your request over the phone. 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. Paul, mn 55164 please refer to current pre authorization lists to verify if service requires pre authorization. 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. Medicaid service authorization dispute resolution request form, medicaid only bcchp and. 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. Prior authorization blue cross and blue shield of illinois. 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.
Abortion x health care professional must submit required hfs form 2390 with the claim submission admissions x inpatient admission yes, prior authorization required. Prescription drug prior authorization and step therapy exception request forms. Prior authorization and step therapy programs blue cross blue. Drug prior approval requests may be submitted using the following methods. 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. 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. Print, type or write legibly and complete the form in full. If you are providing service to outofarea blue cross and blue shield bcbs members, please note. Some bcbs plans have radiology management programs, other than aim. 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. If you are providing service to out of area blue cross and blue shield bcbs members, please note.
Coordination of benefitsblue cross and blue shield of alabama is host plan. Prior authorizationcoverage determination form pdf, 6 kb. Prior authorizationstep therapy program blue cross blue. 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 exceptionprior authorization request form. Prior authorization health insurance can be complicatedespecially when it comes to prior authorization also referred to as preapproval, preauthorization and precertification.
Expedited preservice clinical appeal form, commercial only. Prior authorization forms provider blue shield of ca. Predetermination request form blue cross blue shield of illinois. The drug authorization request form may be downloaded from an insurers website. Texas standard prior authorization request form for health. Online prior authorization form pdf forms are available below to submit a prior authorization through fax. Your standard authorization form a standard authorization form lets you decide how bcbsil can share your phi.
Blue cross blue shield of texas is committed to giving health care providers with the support and assistance they need. Quantity limits exception form external link pdf document. Prior authorization, step therapy, formulary exception. For urgent or expedited requests please call 18007114555. Prior authorizationutilization management blue cross and. Bcbs il pt request form20 59008 activated, traditional. Selfinsured and custom fully insured groups offer a variety of these programs to help. Prior authorization health insurance can be complicatedespecially when it comes to prior authorization also referred to as preapproval, pre authorization and precertification. Emergency room inpatient 23hour observation it is the responsibility of the ordering provider to request prior authorization approval for services. Member authorization form blue cross blue shield of illinois.
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