Highmark outpatient bh aba authorization request form

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Browse a wide variety of our most frequently used forms. Can't find the form you need? Contact us. Individual plans. Medicare Advantage plans.

Note: Carewise audit appeals should go directly to Carewise as noted in the letter sent to providers. Provider appeal submission with authorization - Resolve billing issues that directly impact payment or a write-off amount.

Note the different fax numbers for clinical vs. Member authorization is embedded in the form for providers submitting on a member's behalf section C. View our Medicare Advantage page or individual plans page for additional appeal forms. Policy reconsideration - Request reconsideration of a coding policy.

Corrected claim cover sheet - Correct billing info, codes or modifiers, or add an EOP on a previously processed claim. For more details, see our corrected, replacement, voided, and secondary claims section. Support document cover sheet - Submit medical records or other required supporting documentation to process a claim. Incident questionnaire - Use when a patient has sustained an injury or was involved in an accident.

Other coverage questionnaire enrollment - Provide information about a patient's other healthcare coverage. Balance billing protection act dispute — Providers or facilities not contracted with Premera can submit a balance billing dispute request.

The form must be received by Premera within 30 days from receipt of the original payment notification. Find out more about the Balance Billing Protection Act. Overpayment notification - Notify Premera of an overpayment your office received. Use this form for your documentation purposes. Admission notification and discharge notification. Learn more about submitting prior authorization , including for DME. General prior authorization request.

Out-of-network exception request - Request in-network benefits for an out-of-network service. Durable medical equipment DME. Total joint replacement exception request - Specific to Washington small group members requesting a provider or facility that isn't a Premera-Designated Center of Excellence for total knee or hip replacement.

Pharmacy pre-approval request. Opioid attestation — Specific to School Employees Benefits Board SEBB members undergoing active cancer treatment, hospice, palliative care, end-of-life, or medically necessary care who might be exempt from quantity limits. For expedited authorization codes, call Premera pharmacy services at ProviderSource is free and requires:.

Call New Directions at to obtain precertification and preauthorization information. If medical records are requested for review, send the records to:. Or you can submit your request electronically.

Information , Precertification. NIA prior authorizes or manage the provider precertification for Musculoskeletal Surgery Services, and not the facility precertification. Request , Surgery , Spinal , Precertification , Spinal surgery. PHONE: For other lines of business: Please use other form. Note: Botox and Myobloc are non-preferred. The preferred products are Dysport and Xeomin. All fields must be completed and legible for precertification review. Surgery , Precertification.

Prior Plan Approval PPA precertification before services occur required for certain health care services. Treatment must meet urgent care criteria. Must meet emergency care criteria. If no, and these services require prior authorization, we will resolve your appeal request for benefit coverage as expeditiously as possible and within the time Precertification or prior authorization not obtained.

Request for in-network benefits. Benefit plan exclusion or limitation. Precertification , Cigna , Requires. Precertification is required unless you are having the test as an inpatient in a hospital.

If you do not call, you will pay a larger part of the cost. If the test or procedure is determined not to be medically necessary, you will be responsible for the entire cost. In addition, a plan or issuer may not, under federal law, require that a physician or other healthcare provider obtain authorization for prescribing a length of stay of up to 48 hours or 96 hours.

However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification. For infor-. Life , Precertification , Lowe , Requires , My lowe s life.

The Cigna C. MAY require precertification or other reasonable medical management technique or practice depending on benefit plan design Breast Cancer Screening: women age 40 and older, with or without clinical breast exam, every years Note: ACA utilizes the USPSTF recommendations on breast cancer screening.

Precertification , Cigna , Requires , Require precertification. Medically necessary treatment for an individual with gender dysphoria may include ANY of the following services, when services are available in the benefit plan: Behavioral health services, including but not limited to, counseling for gender dysphoria and related.

Precertification required in U. Additional information : Please submit all appropriate clinical information , provider contact information and any other required documents with this form to support your request. If this is a request for extension or modification of an existing authorization from Blue Cross, please provide the authorization number with your submission. Information , Request , Authorization , Precertification , Prior , Prior authorization precertification request.

How to request precertification for an admission or get prior approval for Other services 24 Non-urgent care claims 25 Urgent care claims 25 Concurrent care claims Coverage information 9. When you lose benefits General features of our Standard and Basic Options PA Prior Authorization sometimes referred to as precertification 3 — Requires your doctor to provide information about why you are taking a medication to determine how it may be covered by your plan.

Box Chattanooga, TN Maximum Reimbursable Amount. Non participating anesthesiologist, radiologist, or pathologist requesting in-network benefits. Review , Professional , Payments , Precertification , Professional payment review. You can call to request a copy of either If you need mental health, behavioral health, or substance Request , Surgery , Spinal , Precertification.

Information , Request , Spinal , Precertification. Request MUST include medical documentation to be reviewed for medical necessity Medical Precertification www. Aetna , Request , Precertification. Precertification Work Categories. Prime providers and subproviders may be precertified in the technical groups and categories in accordance with the listed requirements. A firm may only use an individual who is employed by that firm at the time of submittal for precertification. Precertification , Categories.

The list of standard services requiring pre-certification is located online at. For an observation exceeding 23 hours, failure to contact utilization management on the. Precertification request Amerigroup prior authorization: Fax: To prevent delay in processing your request, please fill ….

Request , Precertification , Precertification request. Example: stock market. At a glance - Aetna www. A how-to guide for health care professionals who Specialty Medication Precertification Request - Aetna www.

Immune Globulin Therapy Medication Precertification Pegfilgrastim Precertification Request Aetna Procedures, programs and drugs that require precertification www. Alpha 1-proteinase inhibitor human precertification for the drug and site of care required : Aralast NP alpha 1-proteinase inhibitor, J Precertification. Hyaluronates Injectable Medication Precertification Request www.

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Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania.

Quick Links: Manuals. Highmark Provider Manual. Medical Policy Medical Policy. Medical Policies. Medicare Advantage Medical Policies. Requiring Authorization. Pharmacy Policy Search. Message Center. Manuals Highmark Provider Manual. Quick Links: Manuals. Highmark Provider Manual. Medical Policy Medical Policy.

Medical Policies. Medicare Advantage Medical Policies. Requiring Authorization. Pharmacy Policy Search. Message Center. Manuals Highmark Provider Manual. After February 1, , all other phone numbers will be discontinued.

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Quick Links: Manuals. Highmark Provider Manual. Medical Policy Medical Policy. Medical Policies. Medicare Advantage Medical Policies. Requiring Authorization. Pharmacy Policy Search.

Message Center. Manuals Highmark Provider Manual. After February 1, , all other phone numbers will be discontinued. Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania.

Quick Links: Manuals. Highmark Provider Manual. Medical Policy Medical Policy. Medical Policies. Medicare Advantage Medical Policies. Requiring Authorization. Pharmacy Policy Search. Message Center.