Blue cross blue shield federal employee program prior authorization form pdf. External links open in new windows to websites Blue Cross and Blue Shield of Louisiana does not control Download a form from the Forms & Resources section of the Evicore website and fax it to 1-888-693-3210 Call 1-888-233-8158 from 8:00 a 2 - Express Scripts data on file, 2019 Take the appropriate request form to your physician for completion Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department 25 Technology Place Hingham, MA 02043 Tel: 1-800-366-7778 Fax: 1-800-583-6289 Prior Authorization Information Outpatient For services described in this policy, see below for products where prior authorization IS REQUIRED if the procedure is performed outpatient If the request has not been approved, the letter will tell you the steps to appeal the decision 2022 Commercial Medical Surgical Prior Authorization Code List - Updated 7/1/2022 Prior authorization must be obtained prior to the delivery of HMO coverage is offered by Health Options, Inc PPI – FEP MD Fax Form Revised 7/29/2021 Send completed form to: Service Benefit Plan Prior Approval P Pre-certification required Find information on the available plans and their benefits All home health and hospice services 800-782-4437 Central Time: Federal Employees: 1-800-492-8872: Monday through Friday, 7:00 a For help with these documents, please call 1-800-722-3130 , Maryland and Northern Virginia Actemra IV ® Actemra SC ® Inquiry / Request Forms To submit a claim online, visit Blue Cross Blue Shield Global Core ®, or print out the form below offer an enhanced Interactive Voice Response (IVR) system that lets you and your office staff Information about how CareFirst's wellness forms for providers and physicians in the CareFirst BlueCross BlueShield network Lists for BCBSAZ-TPA co-administered employer group plans with ; customized; • UsePCP -HMOfax form (available inthe secure provider portal): 1 844 263 The Live Better Louisiana 2022 program year runs from Oct Disclaimer: Some employer groups have some specific items that require *This list is current as of 03/01/2022 (Form MC547C) Home Delivery Order Form (Mail Order Form) (offsite link) Value Blue Income Verification Form for External links open in new windows to websites Blue Cross and Blue Shield of Louisiana does not control Pharmacy prior authorization: Please contact CVS Caremark at 877-433-2973 (Monday — Friday from 8 a The form also may be used to request review of a previously denied Predetermination of Benefits Independent licensees of Prescription Drugs and Supplies Claim Prior Authorization Services For Fully Insured and ASO; Federal Employee Program (FEP) General Reimbursement Information Kidney transplants will now require prior approval and are now part of the Blue Distinction Centers for Transplants ® Home Back to Federal Employee Program Forms, Printables & Resources QP64-22 EquiClaim Expanding Hospital Bill Validation Services Providers may call Magellan Rx for authorization requests at 800-443-5709 Druing your web experience you may be transferred to the Prime Therapeutics website Call Clinical Pharmacy Operations at 1-800-366-7778 Step Therapy Program Criteria Summary and Fax Form List Blue Cross and Blue Shield of New Mexico (BCBSNM) is committed to implementing coverage changes to comply with ACA requirements and to better meet the needs and expectations of you and your patients The prior authorization/step therapy program at Blue Cross and Blue Shield of Texas (BCBSTX) is designed to encourage safe, cost-effective medication use Save money on your health insurance premium through Live Better Louisiana, an OGB program that gives Blue Cross plan members resources to help you better monitor your health, understand your risk factors and make educated choices that keep you healthier BMI of 35 or greater pdf • 37 KB Renewal Audit Package [PDF] High-tech radiology - This includes procedures for Michigan Blue Cross and Blue Shield Federal Employee Program ® members, for dates of service on or after Feb ) eForm (Commercial members) Submit the appropriate eForm com (offsite link) Box 52080 MC 139 Phoenix, AZ 85072-2080 Attn Referring/Prescribing Provider: Name: Street Members You’ll Receive a Notice Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided Authorization of Use/Release of Protected Health Information (PHI) Automatic Bank Draft Blue Cross and Blue Shield of New Mexico refers to HCSC Insurance Services Company (HISC), which is a wholly owned subsidiary of Health Care Service Corporation (HCSC), a Mutual Legal Reserve Company Alaska DME prior approval form Washington DME prior approval form We use evidence-based clinical standards Providers Prior authorization and step therapy are two of our tools Blue Cross Blue Shield of Michigan and Blue Care Network work to make sure you get the safest, most effectiveand most reasonably priced prescription drugs The advanced tools of the editor will lead Home Infusion Therapy Prior Authorization Form Federal Employee Program members: 1-888-282-1315 Blue Cross Blue Shield of Massachusetts employees: 1-617-246-4013 Blue MedicareRx members should be routed to Anthem Blue Cross Blue Shield: 1-866-827-9822 Supervision via Telehealth Request & Attestation R ; Pages 4-5 : 01/01/22 A prior authorization is not a guarantee of benefits or payment Blue Cross Blue Shield of Oklahoma Medical Care Management P 2/1/2022 Member Authorization Form: PDF: Newsletters A UM program requires a Medical Necessity determination prior to the coverage of Clinical edit disagreement – with the appeal, submit supporting documentation (such as CMS) showing correct billing Federal Employee Program (FEP) Non-Network Claims-Direction of Payment 62 Claims Re-submission (Re-filing) 62 Services That Requiring Authorization Prior to Rendering Services 163 Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc Here, you can find a doctor, compare plans, view dental and vision information or download forms COVID-19 premiums Laboratory Codes S Newsletter CAA Federal Employee Program medicare Medicare Advantage precertification Prior Authorization Provider Directory Information qbrp State of Kansas Employee Health Plans Behavioral Health BlueCard Blue Health Initiatives B Newsletter community EFT grants KDHE Medical Necessity Criteria newsletter Resources ** • Call AIM at one of these numbers: o Mail to: Blue Cross & Blue Shield of Rhode Island Small Group Underwriting Recertification Unit 500 Exchange Street, Providence, RI 02903 These manuals set forth the detailed policies, procedures and requirements necessary for participation in the BCBSTX contracting provider networks Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association Getting Started with Anthem; Credentialing; Employee Assistance Program (EAP) COVID-19 Info Patients who are unable or unwilling to provided by reason blue, prior authorization of blue cross shield association, based on the date that parent has been established pursuant to furnish medicare August 12, 2022 To determine if an authorization is required, please always verify each member’s eligibility, benefits and limitations prior to providing services Michigan providers should attach the completed form to the request in the e-referral system Uniform Prior Authorization Form: Commercial Only: Synagis Prior Authorization Form: Medicaid (BCCHP only) Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association To view this file, you may need to install Highmark Blue Cross Blue Shield West Virginia P Service & Support; FAQs; Find an Event; Public Service Recognition; About Us; 1 results found for search term : prior authorization forms If the provider is contracted directly with Arkansas Blue Cross and Blue Shield, non-urgent authorizations also may be done through the secure Magellan Rx secure provider portal at www Use these forms for Arkansas Blue Cross metallic and non-metallic medical plans members only Echocardiogram services View requirements for Basic Option, Standard Option and FEP Blue Focus If the medicine is not approved, refer to the written authorization that was received or will be received in the mail (For Federal Employee Program members, call CVS/Caremark at 1-877-727-3784 2022 Specialty Drugs and Infusion Site of Care Prior Authorization Code List - Updated 7/1/2022 In Massachusetts, call 1-800-689-7219 or fax 1-888–282–1315 Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department 25 Technology Place Hingham, MA 02043 Tel: 1-800-366-7778 Fax: 1-800-583-6289 Prior Authorization Information Outpatient For services described in this policy, see below for products where prior authorization IS REQUIRED if the procedure is performed outpatient , comply with applicable federal civil rights laws and do not exclude people or treat them differently on the If you get your health plan through your employer, you can use this form to update us when you have any changes to your status Jun 21, 2022 Once a request is submitted, you can visit HealtheNet to check the status of a prior authorization Select Line of Business or Member Prefix* Review the prior authorization/step therapy program overview list to help you determine which prior authorization form is used for the medication being prescribed Our Interactive Care Reviewer (ICR) tool via Availity is the preferred method for submitting prior authorization requests, offering a streamlined and efficient experience for providers requesting inpatient and outpatient medical or behavioral health Agency Benefits Officers PDF On behalf of the many independent BCBS Plans, the Blue Cross and Blue Shield Association (BCBSA) contracts with the Office of Personnel Management (OPM) to provide health benefits to eligible federal employees and retirees as authorized by Anthem offers healthcare options for federal employees and their families Telephone Inquiries – Call the prior authorization number on the back of the member's ID card Please see the appropriate National Coverage Determination (NCD) or Local Coverage Determination (LCD) through the CMS website for specific genetic testing guidelines This plan focuses on breaking down the financial, cultural, and linguistic barriers preventing low-income families and individuals from accessing health care Submitting prior authorization requests to AIM Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association Jun 29, 2022 " This tool can be used to check if a prior authorization is required for health care services covered by Blue Cross and Blue Shield of Minnesota commercial health plans, Medicare Advantage and Platinum Blue For questions about a prior authorization covered under the pharmacy benefit, please contact CVS Caremark* at 855 Welcome to the BlueChoice site for Federal Employees! This site is for the exclusive use of Federal Employees in D Below is the list of specific services in these categories that require precertification We use established clinical guidelines to confirm medical necessity when your health plan requires prior authorization Select Blue Cross Blue Shield Global™ or GeoBlue if you have international coverage and need to find care outside the United States Retail Pharmacy Fax: 1-844-490-4877 IPA Infertility Guidelines Fax or Mail: Complete the Predetermination Request Form and fax to BCBSTX using the appropriate fax number listed on the form or mail to P Provider Policy and Procedure Manual (PDF) Credentialing Policy Manual (PDF) What to include with the completed Prior Approval form [pdf] Member Information Advanced benefit determination (ABD) review is an expanded customer service function for FEP It includes: Prior Authorization By fax: Request form 2 Fillable - Submit form to: Blue Cross and Blue Shield of Texas Federal Employee Prior Authorization Prior authorization is a prior review of all services including inpatient stays that are medically necessary as well as services and supplies covered under the Provider Agreement of the member’s Benefit Plan It was formed in 1982 from the merger of its two namesake organizations: Blue Cross was founded in 1929 and became the Blue Cross Association in 1960, while Blue Shield Authorizations Blue Cross Blue Shield of Alabama Prior Authorization Form 2008-2022 No thyroid or endocrine disorders Medical Injectables Fax: 1-844-493-9206 , Eastern, Monday through Friday InterQual ® and Clear Coverage™ are trademarks or registered t rademarks of McKesson Corporation and/or one of its subsidiaries, an independent company providing services for Blue Cross and Blue Shield of Nebraska, an Independent Licensee of the Health Insurance Alabama | Blue Cross and Blue Shield of Alabama CVS Caremark Prescription Drug Program Skilled nursing facility admissions: Empire Blue Cross Blue Shield Benefits Management Program Substance abuse services: Beacon Health Options, Inc Strong and stable Wyoming-based company Medical Records Documentation Standards Clinical Services Fax: 1-877-378-4727 Message: Attached is a Prior Authorization request form Apr 22, 2022 Disability Claims at 1-800-676-BLUE (2583) To request an authorization for Then Commercial members Call 1-800-327-6716 or fax 1-888-282-0780 Medicare HMO and PPO members Call 1-800-222-7620 or fax 1-800-447-2994 Federal Employee Program (FEP) Contact your local plan 1-888-282-1321 Medicaid; Medicare; Get an overview of the prior authorization process and requirements You can use this form to start that process HCSC is a Medicare Advantage organization with a Medicare contract This form must be completed by the member and/or provider for any Blue Cross and Blue Shield of New Mexico Prior Authorization Requirements; Prior Authorization Lookup Tool; A library of the forms most frequently used by health care professionals Prior authorization is a review and approval before a service happens to determine whether it’s Employee Assistance Program; Blue365 member discounts; Leading change QL, PA If Quantity Limit is exceeded, Prior Authorization may apply ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name Phone Central Time Federal Employee Program (FEP) To verify eligibility and benefits and/or check claim status for FEP members Learn More Federal Employee Program (FEP) Employee Change Form Active in Wyoming’s health care market since 1945 This section contains documents to assist with BlueCard questions Both HISC and HCSC are Independent Licensees of the Blue Cross and Coverage of Handicapped Dependent Child Application * You will be notified when an outcome has been reached Since 2014, Anthem Blue Cross and Blue Shield of Georgia (Anthem) has provided medical claims administration and medical management services for the State Health Benefit Plan (SHBP) Services requiring Pre-Certification: Blue Cross and Blue Shield of Oklahoma (BCBSOK) is required by federal and state law to give a notice to plan members about how we can use and disclose their personal health and financial information Visit iLinkBlue, then click on “Blue Advantage” under the “Other Manscrouss of blue cross blue shield of louisiana prior authorization form For more information, visit our COVID-19 information page In 2018, FEP will continue to offer comprehensive benefits—including medical, dental Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association Prior Authorization Program Information Drugs included in our Prior Authorization Program are reviewed based on medical necessity criteria for coverage Forms by The Blue Cross and Blue Shield Service Benefit Plan, also known as the BCBS Federal Employee Program® (BCBS FEP®), has been part of the Federal Employees Health Benefits Program (FEHBP) since its inception in 1960 Note: In the event of a conflict between the manual and the provider's contract, the contract will govern If you have questions or concerns regarding these programs, please call Prime Therapeutics at 800-991-5643 For the most current information, check here regularly for updates Back Admin 22 Starting Oct Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue The documents below are available in DocuSign® format only Formulario de Autorizactión para girar cheques contra mi cutenta (Spanish version of Automatic Bank Draft form) Change of Status Premera Blue Cross Blue Shield of Alaska is an Independent Licensee of the Blue Cross Blue Shield Important Forms Links to third party websites are provided for informational purposes only and by providing these links to third party websites, Blue Cross & Blue Shield of Mississippi does not WASHINGTON – The Blue Cross and Blue Shield Federal Employee Program® (FEP®) announced today that it will waive cost-sharing for coronavirus diagnostic testing, waive prior authorization requirements for treatment and take other steps to enhance access to care for those needing treatment for COVID-19 to ensure its members can swiftly access the right care This information applies to prescription drug coverage for Blue Cross and Blue Shield of New Mexico (BCBSNM) individual plans and employer-offered plans, as well as health plans offered on and off the New Mexico Health Insurance Exchange FOR TPN THERAPY, USE MEDICAL POLICY #296 REQUEST FORM This contractual arrangement with the Federal Government is known as the Federal Employee Program (FEP) View Part D prior authorization requirements This is a library of the forms most frequently used by health care professionals This Plan is underwritten by participating Blue Cross and Blue Shield Blue Cross and Blue Shield of Oklahoma is the only statewide customer-owned health insurer in Oklahoma Please be sure to include your own contact information in case Highmark West Virginia or the PAC Policies and Responsibilities Other Forms Use it to select or change your primary care physician tablet or capsule), and works in exactly the same way as its brand name counterpart Limited distribution specialty drugs - January 1, 2022 Hold harmless policy Federal Employee Program Medical Policy and Prior Authorization for Out-of-Area Members 24/7 online access to account transactions and other useful resources, help to ensure that your account information is available to you any time of the day or night You’ll also find information on fraud, waste and abuse, credentialing, medical management, EDI, newsletters, provider alerts and a frequently asked questions section Prime Therapeutics Partnership Manuals Forms View the FEP-specific code list and forms Transplants with the exception of cornea and kidney 800-432-0272 Affidavit for Deceased Members 1-866-577-9678 During the Public Health Emergency (PHE), over-the-counter (OTC) COVID-19 FDA-authorized test kits are covered for eligible members and will be reimbursed with no member cost share based on the federal guidance Review your request status/decision online A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan Get quality care and attention that works for your employees and business needs 1-800-447-7828 Dependent Child Affidavit * Dallas, TX 75265-0267 For Blue Cross commercial and Medicare Plus Blue: 1-800-728-8008 For some services listed in our medical policies, we require prior authorization Employee Information and Direct Deposit Form (PDF) Members with any service prior to January 1, 2013, are classified as Tier 1 participants Medical Policies; Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Prior authorization is required from BCBSTX for all inpatient, partial hospitalization and outpatient behavioral health services Prior Authorization Updates Denial of MH-TCM services is defined as the initial determination that a member does not meet the criteria for MH-TCM services Florida Blue will mail you a letter confirming that your medical service have been approved or denied 4/1/2021 COVID-19 Resource Center; Main Content Enrollment codes for this Plan: 104 Standard Option - Self Only Please see your benefit booklet to determine what services require precertification under your plan Statewide leader in finding solutions to community health issues Medical Customer Service Fax to: Small Group Underwriting - Recertification Unit at (401) 459-5445 Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Sponsored and administered by: The Blue Cross and Blue Shield Association and participating Blue Cross and Blue Shield Plans Who may enroll in this Plan: All Federal employees, Tribal employees, and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program Enrollment codes for this Plan: 131 FEP Blue Focus - Self Only The Behavioral Health Program also allows the Behavioral Health team to “touch” every member who uses behavioral health care services via our state-of-the-art analytics to identify those who could potentially benefit from our array of programs and services Federal Employee Program FEP Blue Cross was Blue blur of Alabama Through the BCBSMT IVR you will be able to request PA for some: Inpatient services; Outpatient services Prior authorization, sometimes called pre-certification, is how Blue Cross and Blue Shield of Minnesota makes sure the treatment your doctor prescribes is medically necessary and helps ensure you are getting proper care , diet, exercise, drugs) for at least 6 consecutive months Through the BCBSMT IVR you will be able to request PA for some: Inpatient services; Outpatient services Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department 25 Technology Place Hingham, MA 02043 Tel: 1-800-366-7778 Fax: 1-800-583-6289 Prior Authorization Information Outpatient For services described in this policy, see below for products where prior authorization IS REQUIRED if the procedure is performed outpatient 1-800-253-4091 (TTY) Note: For medical emergencies, call 911 or your physician first Products and services are 2 days ago · Register for MyBlue Federal Employee Plan (FEP) Medicare; State Health Benefit Plan; Articles by Date BCBSGa accepts electronic medication prior authorization requests for commercial health plans Menu of Forms, Printables & Resources Member Forms Outpatient Prior Authorization CPT Code List (072) Prior Authorization Quick Tips; Forms Library; Non-covered services Dec Box 660044, Dallas, TX 75266-0044 Thinking ahead ® Registered marks of the Blue Cross and Blue Shield Association Proton beam therapy If you have BlueRx Mail, you can download a mail order form on this site or on express-scripts LET’s GET STARTED Outside the United States Together we look for ways to help our members get the medication they need to feel better and live well, while delivering the most cost-effective drug coverage Effective 1/1/2022, our Blue Cross and Blue Shield of Texas (BCBSTX) Federal Employee Program (FEP ®) participants will have some changes to their prior authorization requirements and benefits Please note: six forms are required to submit a Disability benefits claim ) This section provides information about policies and responsibilities that Blue Medicare HMO and Blue Medicare PPO plans have implemented to maintain the high quality care for its members Because your Mortgage Plan claim is related to a leave of absence, you must complete the claim forms for disability benefits, which are included in the claimant's guide to disability insurance Explore the right plan to cover your healthcare needs Medical oncology - This applies to the following: Medicare Plus Blue members For services outside Alaska or Washington 3645 Alice Street Fax the completed form to 1-844-429-7757 within one business day of the determination/action Please contact the local Blue plan where the Prior authorization requests for our Blue Cross Medicare Advantage (PPO) SM (MA PPO), Blue Cross Community Health Plans SM (BCCHP SM) and Blue Cross Community MMAI (Medicare-Medicaid Plan) SM members can be submitted to eviCore in two ways 5 million federal employees, retirees and their families out of the nearly 8 million people who receive their To request coverage for a contraceptive not listed in the member's formulary, please contact customer service at 1-866-482-2250, and request to speak with a member of the Pharmacy Escalation Team This is a fee-for-service plan with a preferred provider organization (PPO) sponsored and administered by the Blue Cross and Blue Shield Association and participating Blue Cross and Blue Shield Plans such as Florida Blue A generic drug has the same active ingredient and dosage form (e Eastern time Insulin Saver Program - January 1, 2022 The oral chemotherapy medication list includes drugs on our Commercial formulary Referring/Prescribing Provider: Name: Street Federal Employee Program® AIM Radiology prior authorization review transition delayed until November Iron Infusion Prior Authorization Update; Services provided by Empire HealthChoice HMO, Inc Medicare Dallas, TX 75266-0044 The way to complete the Blue cross blue shield of Illinois and IVG form on the internet: To begin the document, utilize the Fill camp; Sign Online button or tick the preview image of the document New York, NY 10008-3876 COVID-19 Info Close Menu South Carolina Midlands or Upstate: 800-444-0025; South Carolina Charleston Area: BlueChoice HealthPlan of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association To do this, use iLinkBlue PO Box 3876, Church Street Station Federal Employee Program; CareFirst Direct User Guides; News/Training; Learning and Engagement Center BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Prior Authorization Prior Authorization Request Form This form is for members who have individual or family, or employer-sponsored coverage through Blue Care Network Resources for ABOs Box 1353 Charleston, WV 25325 Email:pac@highmark May 3, 2022 Blue Cross and Blue Shield of Texas (BCBSTX) has contracted with eviCore healthcare (eviCore)* to provide certain utilization management prior authorization services for our government programs Pre-Authorized Debit Agreement You may also view the prior approval information in the Service Benefit Plan Brochures Medical Management Correspondence for Exchange Members: 866-589-8254 What is prior authorization? Blue Cross and BCN require a review of certain Behavioral Health Blue Cross and Blue Shield Medicare Program Provider Orientation Who may enroll in this Plan: All Federal employees, Tribal employees, and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program Customer Services Blue Cross encourages the use of the EPA system to effectively and efficiently respond to your request Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, If you have a problem with your Blue Cross Blue Shield of Michigan service, you can use this form to file an appeal with us Forms and documents related to making inquiries or submitting various types of requests including requests for changes to an existing enrollment, requests for a predetermination for an upcoming medical or dental expense, request for authorization, etc Register for MyBlue The Health Insurance Portability and Accountability Act of 1996 (HIPAA) helps to protect your privacy What’s Changing: Blue Cross and Blue Shield of New Mexico (BCBSNM) is changing prior authorization requirements that may apply for some commercial and Medicaid Blue Cross Community Centennial SM members to reflect new, replaced or removed codes due to updates from Utilization Management or the American Medical Association Search by a procedure code or enter the procedure description You will be provided the prior authorization requirement or directed to the potential medical policy for additional clinical criteria Blue Cross Blue Shield of Arizona, Mail Stop A115, P to 2 p We have a suite of programs, designed to meet the needs of your workforce mrxgateway It is subject to change Through Anthem, SHBP offers eligible members, including pre-65 Retirees a choice of three Health Reimbursement Arrangement (HRA) Plan Options: Gold HRA, Silver HRA Notice: The Federal Employee Program has a 15 Day turn-around time on all Prior Authorization Requests according to the Blue Cross Blue Shield Service Benefit Plan To see all available Qualified Health Plan options, go to the New Jersey Health Insurance Marketplace at Get Covered NJ Learn more about Prior Authorization Discover the benefits you want with the affordable coverage you need Acuity Connect is a portal designed to allow providers the ability to view and submit prior approval and pre-notification requests electronically The terms of the member's plan control the available benefits Please call customer service number on the back of your member ID card We update these manuals periodically when new information becomes available Check back with the pharmacy to see if the prior authorization was approved com All in-patient medical stays (requires secure login with Availity) 800-782-4437 If you have not received a response after two business days from when your completed form was submitted, please contact the physician who requested your prior authorization 2022 Behavioral Health Prior Authorization Code List - Updated 1/1/2022 Providers must obtain prior authorization from AIM before these services are provided Certain prescription drugs and supplies require prior approval Care-Related Box 660044 , and The Dental Network, Inc MedWatch Form Interactive Most medications requiring prior authorization: Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) Hepatitis C medications: • Group Purchaser Name: Blue Cross and Blue Shield of Minnesota • Group Purchaser Contact Name (if available): Clinical Review Department • Group Purchaser Address: 1305 Corporate Center Drive • City, State, Zip: Eagan, Minnesota 55121 • Group Purchaser Phone: 1-866-202-3474 • Secure Fax #: 1-877-480-8130 1, 2021 - Sept Contact Provider Services at 1-866-518-8448 for forms that are not listed Learn more CST) to request approval for a prescription drug that requires a prior authorization For full BA online provider services, such as claim status checks, member eligibility, benefit verification or confirmation of prior authorization, use our Blue Advantage Provider Portal licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross Independence Blue Cross (IBX) offers affordable health care, dental, vision and Medicare plans in Philadelphia and southeastern Pennsylvania Insurance Plans Blue Cross And Blue Shield Service Benefit Plans pdf • 215 KB (Form 29-158) Duplicate Coverage Questions * Kansas City, MO 64141 Introduction This brochure describes the benefits of the Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Standard and FEP Blue Basic Options under our contract (CS 1039) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law In-network providers will be paid at their contracted rate Use this form to submit a claim for a prescription drug charge for any BlueRx product, excluding BlueRx Direct Contact CVS Caremark the Pharmacy Program administrator at 1-800-624-5060 (TDD: 1-800-624-5077 for hearing impaired) Blue Essentials Brochure These manuals set forth the detailed policies, procedures and requirements necessary for participation in the BCBSTX contracting provider networks If you wish to authorize a person or entity to receive your personal health information (PHI) from the Eligibility and Enrollment Support Center on your behalf, please complete 08/10/2022 Federal Employee Program (FEP), and Medex®´ plans Dependent Student Medical Leave Certification Form Fax number to send determination Employee Assistance Program; Blue365 member discounts; Leading change Electronic Funds Transfer Authorization 1, 2021 Use our tool to see if prior authorization is required Exceptions for 1) prescription drug fertility treatments, 2) dosages in excess of the plan’s quantity limits, 3) step therapy, and 4) drugs Note: For Blue Cross and Blue Shield Federal Employee Program ® non-Medicare members, you can submit requests through NovoLogix or by fax for dates of service on or after Dec Claims denied for timely filing For Services requiring prior authorization through eviCore are outlined Blue Cross Federal Employee Program ® Use these forms to obtain prior authorization for administering medications in physician's offices and outpatient hospitals, including urgent care, hospital-based infusion care centers, and clinics where the drug is injected or infused and billed on a UB04 or CMS 1500 form Our experience has been that members who have consistent support throughout all Anthem blue cross prior authorization pdf free form pdf (Requests received without the member/patient's group number, ID number, and date of birth cannot be completed and may be returned Prior Authorization of Cardiology and Radiology Services Upload date Submitting these forms in the DocuSign format allows the Provider Credentialing & Data Management staff to continue processing your requests as our employees take precautionary measures to prevent the spread of the novel Coronavirus Blue Cross Federal Employee Program ® Use these forms to obtain prior authorization for administering medications in physician's offices and outpatient hospitals, including urgent care, hospital-based infusion care centers, and clinics where the drug is injected or infused and billed on a UB04 or CMS 1500 form These companies are Independent Licensees of the Blue Cross and Blue Shield Association Asthma: PDF: Cancer: PDF: Cardiac: PDF: Blue Cross and Blue Shield of North Carolina is Provider manual Referring/Prescribing Provider: Name: These manuals set forth the detailed policies, procedures and requirements necessary for participation in the BCBSTX contracting provider networks 12-105 (09-09) • Submission of this information by fax or phone does not constitute authorization of services Drug formularies Prior authorization Pharmacy policies Blood glucose meter Specialty drugs Direct Ship Drug Program , are independent licensees of the Blue Cross and Blue Shield Utilization Management (Form 34-705) Enrollment Form for Individuals and Families * Authorization is required for Blue Cross and Blue Shield members enrolled in the following programs: • Blue Cross and Blue Shield of Illinois o Medicare members • Blue Cross and Blue Shield of Montana o Medicare members • Blue Cross and Blue Shield of New Mexico o Medicare members • Blue Cross and Blue Shield of Oklahoma o Medicare members August 12, 2022 We use evidence-based clinical standards This form is required if you file a claim for Mortgage Plan; you must also provide proof of the last payments made to the creditor Services are funded in part under a contract with the State of New Mexico The Blue Cross Provider Policy and Procedure Manual, along with the Blue Plus Manual, provides key administrative information including the quality improvement program, the UM program, quality standards for participation and claims appeals 17089-8852 Federal Employee Program claims Pennsylvania Blue Shield PO Box 898854 Camp Hill, Pa Uniform Prior Authorization Form: Commercial Only: Synagis Prior Authorization Form: Medicaid (BCCHP only) Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association To view this file, you may need to install These manuals set forth the detailed policies, procedures and requirements necessary for participation in the BCBSTX contracting provider networks 30, 2021 – Today the Blue Cross® and Blue Shield® (BCBS) Government-wide Service Benefit Plan, also known as the Federal Employee Program® (FEP®), announced 2022 benefits available to eligible participants in the Federal Employees Health Benefits (FEHB) Program and the Federal Employees Dental and Vision Insurance Program 2022 Anthem Dental and Vision Individual Enrollment Application for New York (Empire BCBS) Employee Enrollment Application Change Form/Anthem Balanced Funding - Downstate (274 KB) Employee Enrollment Application Change Form/Anthem Balanced Funding - Upstate (261 KB) NY Employee Disability & Life Application (301 KB) Provider Nomination Form For information regarding Federal Employee Program Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association To view this file, you may need to install a PDF reader program Diagnosed as morbidly obese for at least 5 years Blue Advantage Support Federal Employee Program | Blue Cross and Blue Shield of Oklahoma This page may have documents that can’t be read by screen reader software Most PDF readers are a free download Requests for the following services can be made by fax or mail Premera Blue Cross is an independent licensee of the Blue Cross Blue Shield Association serving businesses and Your health care provider can use any of the following ways to request prior review and certification: By phone: Blue Cross NC Utilization Management at 1-800-672-7897 Monday to Friday, 8 a 2022 FEP Blue Focus; effective on January 1, 2022 Updated: December 23, 2021 2022 Federal Employee Program (FEP) Prior Approval/Pre-Certification List for FEP Blue Focus Please note: There is a separate Prior Approval/Pre-Certification list for the FEP Standard Option and Basic Option products Dental, Life and Disability are offered by Florida Combined Life Insurance Company, Inc For a complete quote of benefit information, please contact the local Blue Cross and Blue Shield plan on the back of the patient’s identification card Fall 2021: PDF: Fall 2020: PDF: Spring 2020: PDF: Read About Your Chronic Condition (Form 15-411) Dependent Child Affidavit * Hospital Coverage Letter All requests for these NOT on our Prior Authorization List Fax form and relevant clinical documentation to (651) 662-6054 Utilization Register for MyBlue If you're a Blue Cross Blue Shield of Michigan member and are unable to resolve your concern through Customer Service, we have a formal grievance and appeals process PO Box 7982 Easily obtain pre-authorization and eligibility information with Prior Authorization Requirements Summary Lists – 06/01/2022 Page 1 2022 BCBSAZ Prior Authorization Requirements Federal Employee Program® (FEP®) plans Most drugs are covered without requiring prior approval The member prefix can be found on the member ID card, before the member ID number If allowed amounts disagree with the contracted rate, multiple same-day reductions, denials for inclusive procedures, or OrthoNet denials Blue Cross Blue Shield of Massachusetts Clinical Intake department at 1-800-689-7219 Box 65067 Education & Training evicore Enrollment in Excellus BlueCross BlueShield depends on contract renewal Mail to: Blue Cross and Blue Shield of Texas QP66-22 Commercial Pharmacy Benefit Exclusion for Amvuttra™ and Skyrizi® Care Coordination Referral Form Respiratory Syncytial Virus IG/ Synagis (MED Not all services and drugs need prior authorization com Phone: (304) 347-7681 To submit a prior authorization request to AIM, use one of the Browse our forms library for documentation on various topics Prior Authorization; Patient Care Patient Care Non-Michigan providers should fax the completed form using the fax numbers on the form g Mail Service Pharmacy Order Form IPA Guidelines for Member Complaints, Inquiries, Appeals and Grievances Postal Service Employee I'm a Retired Federal Employee I'm a Uniformed Services Retiree/Family Member Beginning January 1, 2021, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex®´* plans with a three-tier pharmacy benefit Authorization requirements may vary based on the member’s benefit plan Prior Authorization and Exception Request Forms: Excellus BlueCross BlueShield is an HMO plan and PPO plan with a Medicare contract 17, 2021 Kidney transplants will now require prior approval and are now part of the Blue Distinction Centers for Transplants ® Requests for inpatient authorization for Blue Cross Blue Shield of Michigan members can be submitted directly through your local Blue plan’s electronic portal via the Electronic Provider Access (EPA) system Medical necessity denials that are provider write-offs Permission for One-Time Disclosure of Information [PDF] A form authorizing Blue Cross Blue Shield of Massachusetts to send specific information to a specific individual The portal allows providers to see the status and documentation associated with the authorization submitted Blue Cross Blue Shield Association (BCBSA) is a federation of 35 separate United States health insurance companies that provide health insurance in the United States to more than 106 million people We have partnered with New Directions for their expertise in the provision of behavioral health services For Federal Employee Program members, fax each completed Predetermination Request Form to 888-368-3406 You’ll need to access the provider packet to register or update your information Attn: Provider Administration View Blue Shield Prior Authorization list (PDF, 113 KB) Federal Employee Program Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary, Effective January 1, 2021 Then click “CTRL” and “F” at the same time 1-800-955-5692 Through the BCBSMT IVR you will be able to request PA for some: Inpatient services; Outpatient services Allow the doctor’s office and Horizon BCBSNJ enough time to complete this process Requesting / Performing Provider’s NPI or Provider ID Review the prior authorization/step therapy program overview list to help you determine which prior authorization form is used for the medication August 12, 2022 Claim Forms; Manage Your Health DOWNLOAD Where do you have or need Federal Employee Program members only require prior approval or pre-certification on the following services, which are based on medical necessity Comprehensive 9 Solutions The industry’s most comprehensive clinical evidence-based guidelines 4 Online – The eviCore Web Portal is available 24x7 New Directions also engages with our providers to improve quality outcomes To print or save an individual drug policy, open the PDF, click “File”, select “Print” and enter the desired page range Cheyenne, WY 82001 800-442-2376 TDD 800-696-4710 Durable medical equipment (DME) prior approval forms As of March 17, the PDF versions of these forms are no longer available 1-888-282-0780 †Trade-mark of the Blue Employee Assistance Program; Blue365 member discounts; Leading change If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537 For pharmacy, call customer service for pharmacy benefit drugs Notice: The Federal Employee Program has a 15 Day turn-around time on all Prior Authorization Requests according to the Blue Cross Blue Shield Service Benefit Plan To submit a prior authorization request to AIM, use one of the following methods: • Log in to the AIM provider portal NOTE: Medicare Advantage Determination / Exception can be found on the Medicare Advantage Pharmacy page For information about faxing prior authorization requests, call the Pharmacy Clinical Help Desk at 1 Utilization Management Through the BCBSMT IVR you will be able to request PA for some: Inpatient services; Outpatient services These manuals set forth the detailed policies, procedures and requirements necessary for participation in the BCBSTX contracting provider networks Completed forms received after 12 p Virginia Members Only - Transition Fill Form 2016 Virgin Islands Troy University employees enrolled in Blue Cross Blue Shield will be assessed an annual charge of $228 ($19 per month) for the usage of tobacco products Blue Cross of Idaho’s Medical Management Federal Employee Program: Fax 208-286-3551 q Home Health/Hospice: Fax 208-387-6655 q Inpatient: Fax 208-331-7326 q Procedures/Services: Fax 208-331-7344: An Independent Licensee of the Blue Cross and Blue Shield Association: Federal Employee Program Members 2021-6-28 · Certain drugs require Prior Authorization & Medical Necessity Determination (PA/MND) before coverage is approved (Form 40-127) Please also complete life insurance applications if applicable: Life Insurance Forms Email customer service or call 1 800-492-8872 Maryland Members Only - Transition Fill Form 2020 Blue Cross Blue Shield members can search for doctors, hospitals and dentists: In the United States, Puerto Rico and U Fax to: 972-996-8230 (preferred method) or Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue Cross and Blue Shield Association Predeterminations Simply click on the form name to open them Central Time: All Other Blue Cross Members: 1-800-292-8868: Monday through Friday, 7:00 a This website does not display all Qualified Health Plans available through Get Covered NJ For your convenience, there are 3 ways to complete a Prior Authorization request: Electronically A strong local company PA/MND also: Helps keep the cost of prescription drug therapy affordable View PDF Helena, MT 59604-7982 Utilization Management Skilled Nursing Facility and Acute Inpatient Rehabilitation form for Blue Cross and BCN commercial members Federal Employee Program (FEP Prior Authorization Requests 3 Employee Assistance Program (EAP) Go To Providers Overview Close Menu This change applies to plans with the Blue Cross Blue Shield of Massachusetts formulary, and the National Preferred Formulary (NPF) Box 660712 Dallas, TX 75266-0712 The PA/MND process is designed to assure only medically necessary and appropriate prescription drugs are approved for coverage and/or Empire HealthChoice Assurance, Inc If we request additional clinical: Concurrent review Referrals Box 13466, Phoenix, AZ 85002-3466 Page 1 of 2 Member Information Member Name (first & last): constitute authorization of services To report a serious or adverse event, product quality or safety problem, etc and Southern National Life Insurance Company, Inc Prior authorization requests are submitted on different websites for 2020 individual and non-individual plan members (groups, associations, etc our pharmacy benefit manager, conducts all prior authorization and step therapy preauthorization Prior Authorization Overview to 9:00 p Members of the Federal Employee Blue Cross/Blue Shield Service Benefit Plan (FEP) are subject to different prior authorization requirements Admin 23 This form does not apply to government programs (Illinois Medicaid and Medicare Advantage) or any of our commercial HMO members Blue Cross Medicare Advantage SM has contracted with eviCore healthcare (eviCore), an independent specialty medical benefits management company, to provide Utilization Management services for prior authorization requirements outlined below Phone – Call eviCore toll-free at 855-252-1117 Schedule C (Form 1040) Schedule K-1 (Form 1120s) Schedule K-1 (Form 1065) W-4 Form; Email to: recertification@bcbsri Eligibility and Enrollment Support Center Authorization Request Form If you need preauthorization, contact eviCore in one of three ways: Get immediate approval by submitting your request at www August 12, 2022 101179 0420 June 2020 CVS/Caremark Prior Authorization every quarter to obtain the most current prior authorization forms In-lab sleep management drug prior These manuals set forth the detailed policies, procedures and requirements necessary for participation in the BCBSTX contracting provider networks Blue Care Network Physician Selection Forms to the FDA To expedite prior authorizations, the provider should have the following information: An authorization review can take between 2 to 3 business days to complete Prior Authorization of Drugs Upload date a Mutual Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association Utilization management is at the heart of how you access the right care, at the right place and at the right time Hemophilia Referral Fax QP67-22 MHCP Pharmacy Benefit Exclusion for Amvuttra™, Pemetrexed, and Skyrizi® Translation Services; Blue Cross of Idaho provides health insurance, dental insurance, and medicare advantage coverage to the residents of Idaho — 5 p Submit a prior authorization Reviewed by Blue Cross Blue Shield Admin 56 You can access Acuity Connect via the Provider Resource Center Anthem Blue Cross is the trade name of Blue Cross of California and Anthem Blue Cross Partnership Plan is the trade name of Blue Cross of California Partnership Plan, Inc With a large geographical area and a relatively small population, we are in a unique position to meet the needs of the people who live and work in Wyoming For eligibility, prior authorization or claims inquiries, call 877-299-1008 800-722-3130 877-906-6389 o Fax request – Complete the Prior authorization Request form or the NM Uniform Prior Authorization Form and submit it along with your supporting documentation Request for prior authorization Responsibilities of primary care physicians (PCPs) Reimbursement Policy - Quality Incentive Program 30, 2022 Box 2048 Southeastern, PA 19399 Appeals forms Blue Cross & Blue Shield of Mississippi does not control such third party websites and is not responsible for the content, advice, products or services offered therein Blue Cross® and Blue Shield • Medicare, Medical Assistance or Federal Employee Plan members You can also check status of an existing request and auto For more information on the pharmacy prior authorization process , call the Pharmacy Services department at 1-866-610-2774 You or your physician should fax the completed form to FutureScripts at 1-888-671-5285 for review (Form 34-705) Enrollment Form for Group Coverage * C A prior authorization is the process where we review the requested service or drug to see if it is medically necessary and covered under the member's health plan The Medicaid-Approved Preferred Drug List (PDL) includes information such as mandatory generic requirements, prior authorization (PA), quantity limits, age limits or step Federal Employee Program; CareFirst Direct User Guides; News/Training; Learning and Engagement Center; Medications Added to Prior Authorization and Site of Care Management Lists – Effective September 1, 2022 CareFirst BlueChoice, Inc Blue Cross of Idaho’s Pharmacy Management Prior authorization requests are submitted on different websites for Individual and non-Individual plan members (groups, associations, etc Post-service reviews ET gov or learn about filing a complaint by contacting the Medicare Ombudsman pdf • 6 MB Medical Services Applied behavior analysis (ABA) prior approval forms ICR offers a fast, efficient way to securely submit your requests with clinical documentation FEP Behavioral Health Line Medications that Require Prior Authorization , comply with applicable federal civil rights laws and do not exclude people or treat them differently on the Cross Blue Shield of Michigan on behalf of Blue Cross and Blue Shield Federal Employee Program Michigan members for services received in Michigan 1 - CoverMyMeds Provider Survey, 2019 Keep the letter for future reference Tier Exception Form Contact us if you have a specific Alabama-related question or would like additional information about the products and services available through the Federal Employee Program Behavioral Health Authorization Request Form (Non Portal Users) View PDF The information presented here applies to most Blue Cross & Blue Shield of Mississippi Members, but there may be some differences based on each individual's health and wellness benefit plan Alaska ABA prior approval form (Eastern) Washington ABA prior approval form Blue Cross Community Centennial maintains and monitors a network of Medical forms for Arkansas Blue Cross and Blue Shield plans to 8 p Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) requires prior authorization (PA) for some covered admissions, continued stays, services, procedures, drugs and medical devices before they’re covered WASHINGTON, Sep Enhanced Personal Health Care Join Our Network Join Our Network Blue Cross & Blue Shield of Mississippi does not control such third party websites and is not responsible for the content, advice, products or services offered Complete all member information fields on this form: Complete either the denial or the termination information section org Through the BCBSMT IVR you will be able to request PA for some: Inpatient services; Outpatient services : The Blue Cross and Blue Shield Association and participating Blue Cross and Blue Shield Plans Browse forms for Empire BlueCross BlueShield HealthPlus providers and staff in New York Prior Authorization Lookup Tool; Reimbursement Policies Alternative Dental Claim It covers about 5 Brand name is for reference and may not be covered Federal Employee Program (FEP) members Self-insured and custom fully insured groups offer a variety of these programs to help effectively manage their prescription Pre-certification required Copy of member’s insurance card (front/back) Other Insurance Information Arkansas Formulary Exception/Prior Approval Request Form [pdf] Authorization Form for Clinic/Group Billing [pdf] Use for notification that a practitioner is joining a clinic or group If unable to fax, you may mail your request to BCBSIL, PO BOX 805107, Chicago, IL, 60680-3625 O Hours: Monday to Friday 8 a Check out how easy it is to complete and eSign documents online using fillable templates and a powerful editor ©2022 Blue Cross Blue Shield Empire Blue Cross Blue Shield Drug prior approval is a process to obtain advanced approval of coverage for a prescription drug If you have questions or concerns regarding these programs, please call Prime Therapeutics at 800-544-1378 eviCore is an independent company that provides specialty medical benefits management for BCBSTX Emergent Inpatient Notification The services listed in the table on page 7 require prior authorization before they may be rendered S DBA Florida Blue HMO Printable PDF Forms This feature reduces processing time and helps determine coverage quicker Call 866-325-1794 to check the status of a request Self-insured and custom fully insured groups offer a variety of these programs to help effectively manage their We know PA requests are complex For both outpatient procedures and treatment requiring an inpatient stay, call (800) 633-4581 to obtain prior authorization Current Prior Authorization Requirements (Commercial) Effective 1/1/2022 Help Center All in-patient mental health stays 800-952-5906 Independence Blue Cross is a subsidiary of Independence Health Group, Inc Pharmacy Prior Authorization Request (Commercial only - Please do not use for Medicare Advantage or Federal Employee Program) Form No An independent licensee of the Blue Cross and Blue Shield Association Complete private business claims for services provided to a Blue Shield member on the appropriate claim form and mail them to one of these appropriate addresses: Central Site Accounts claims Pennsylvania Blue Shield PO Box 898852 Camp Hill, Pa include your patients covered by the Federal Employee Program Download the COVID-19 (Coronavirus) Resource Guide (as of June 28, 2021), created especially for our valued customers (M) indicates the pre-authorization is only required for Medex and Blue Care ® 65 members Learn about the types of utilization management reviews – prior authorization , predetermination and post-service review Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity A form to request an amendment to Protected Health Information (PHI) that Blue Cross Blue Shield of Massachusetts maintains in a designated record set Precertification is required for many services, including the following outpatient hospital benefits, physician benefits and other covered services ) Fax information for each patient separately to BCBSMT Fax #: 1- 866-589-8256 to 6:00 p Doctors & Providers Preventive Care Claims & Records Incentives & Pharmacy Program - Blue Cross and Blue Shield of New Mexico International Blue Cross Blue Shield Claim Form; NOTE: International Claim Forms should be sent to: Service Center Behavioral Health Program program for procedures that require a pre-service prior authorization We believe Oklahoma consumers and employers deserve the best of both worlds: access to affordable, quality health care and top-notch service from a company that focuses solely on customers, not shareholders Capital Blue Cross Vision - PA School Trust; International claim forms You can also type part of the code's description to search, for example type "tonsil" to find "Removal of tonsils To obtain prior authorization, call: BCBSTX 1-800-528-7264 Refer to the online Blue Choice PPO Provider Manual (Section I) for more detailed information Home and Community-Based Services & Waivers; Nursing Facilities; Federal Employee Program (FEP) a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association The Value formulary has been enhanced with medications for certain classes of drugs that will be available to members at no cost share 3/1/2021 Medical Policy Select a line of business to see the the list of prior authorizations related to the member details selected Prior Authorization; Long Term Services Or, call our Health Services department at 800-325-8334 or 505-291-3585 Submit a complaint about your Medicare plan at www Our pharmacists do this in many different ways Utilization management review requirements and recommendations are in place to help ensure our members get the right care, at the right time, in the right setting 9k+ employees including 1k clinicians Engaging with 570k+ providers most efficient way to request prior authorization and check authorization status and is This website is operated by Horizon Blue Cross Blue Shield of New Jersey and is not New Jersey’s Health Insurance Marketplace Outpatient Synagis Prior Authorization Form IPA Process for Establishing Out of Area for Emergency Services Outpatient Physical, Occupational and Speech Therapy authorizations MyBlue offers online tools, resources and services for Blue Cross Blue Shield of Arizona Members, contracted brokers/consultants, healthcare professionals, and group benefit administrators Prime Therapeutics serves as Blue Cross' Pharmacy Benefit Manager We use evidence-based clinical standards These Benefit Inquires are also not available for members covered by the Federal Employee Program Blue Cross and Blue Shield of Montana Headquarters Requested service (s) Name and telephone number of contact person Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) prior authorization: 866-518-8448; Fax: 1-800-964-3627 To prevent delay in processing your request, please fill out this form in its entirety with all applicable information Below are several forms you may need regarding your State Health Plan benefits Use this form to submit a claim for a prescription drug charge if you have BlueRx Direct Forms to Download (PDF format) The forms below are all PDF documents Finding the Services & Support You Need Some forms below can be submitted online Blue Cross and Blue Shield of New Mexico's (BCBSNM's) Medicaid plan is Blue Cross Community Centennial SM Processes may differ by plan to 7 p Dec Box 419169 Commercial & Exchange Call the National Information Center at 1-800-411-BLUE (2583) weekdays from 8 a Prescription Reimbursement Claim Form Medicare Advantage March 7, 2022 QP69-22 Skilled Nursing Facility (SNF) Benefit Information for Medicare Advantage Phone: 866-508-7145 pdf • 94 KB , DBA Florida Combined Life That's why we have a team of experts and a variety of help resources to make requests faster and easier Through the BCBSMT IVR you will be able to request PA for some: Inpatient services; Outpatient services Non-Formulary Drug Exception Form You can also use a HIPAA-compliant authorization form found on our website to request certain records m About prior authorization Home Office 4000 House Ave You will be going to a new website, operated on Repetitive Transcranial Magnetic Stimulation (r TM S) Form easily create electronic signatures for To search for a specific drug, open the PDF below Disclaimer: Some employer groups have some specific items that require State & Federal Other Blue Plans’ pre-authorization requirements may differ from ours New Directions manages authorizations for our members, performs all utilization and case management activities, as well as ABA case management 24/7 online access to account transactions and other useful resources, help to ensure that your account information is available to you any time of the day Effective June 1, 2017, Blue Cross Medicare Advantage members will be subject to the prior authorization Fax completed prior authorization request form to 602-864-3126 or email to pharmacyprecert@azblue Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests View and download our medical, pharmacy and overseas claim forms Florida Blue is the servicing agent for the Federal Employee Service Benefit Plan, the Blue Cross and Blue Shield Federal Employee Program ® (FEP) ; Saturday 10 a It includes all the relevant information necessary to continue Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department 25 Technology Place Hingham, MA 02043 Tel: 1-800-366-7778 Fax: 1-800-583-6289 Prior Authorization Information Outpatient For services described in this policy, see below for products where prior authorization IS REQUIRED if the procedure is performed outpatient You must complete and submit a Provider Initiated – Pre-Service/Formal Benefit Coverage Information form [pdf] Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department 25 Technology Place Hingham, MA 02043 Tel: 1-800-366-7778 Fax: 1-800-583-6289 Prior Authorization Information Outpatient For services described in this policy, see below for products where prior authorization IS REQUIRED if the procedure is performed outpatient Documentation of physician supervised non-surgical management weight loss program (e Medical Plans BCBS Florida Pre-Approval Requirements Most HMO groups and standard products plans include this program Review our pre-authorization lists for CPT and HCPCS codes for services that require authorization Federal Employee Program will be considered received on the next business day Blue Cross and Blue Shield Federal Employee Program The BCBSA Federal Employee Program Special Investigations Unit (BCBSA FEP SIU) has the unique responsibility of guiding all a single pharmacy or pharmacy chain for opioid prescriptions and prior authorization for all new short-acting prescriptions exceeding Empire Pharmacy Department The prior authorization/step therapy program at Blue Cross and Blue Shield of Illinois (BCBSIL) is designed to encourage safe, cost-effective medication use 15, 2022, you will be able to use the Blue Cross and Blue Shield of Montana (BCBSMT) interactive voice response (IVR) system to complete some prior authorization (PA) requests for Federal Employee Program ® (FEP) members Request for telehealth services for ABA Prior authorization program with AIM Specialty Health There are services and procedures that must be authorized prior to being performed Failure to complete this form in its entirety may result in delayed processing or an adverse determination for insufficient information The Blue Cross Blue Shield Association is an These manuals set forth the detailed policies, procedures and requirements necessary for participation in the BCBSTX contracting provider networks P We provide Coordination of Benefits Form When prior authorization is required, you can contact us to make this request 1, 2020 Records/Prov Adjust Forms Non-UM Appeals Medicare Advantage Grievance & Appeals Federal Employee Program Claims & Correspondence ; Anthem Blue Cross Blue Shield PO Box 105187 Atlanta GA 30348-5187 Anthem Blue Cross Blue Shiel d PO Box 105557 Atlanta GA 30348-5557 Anthem Blue Cross Blue Shield PO Box 105568 Atlanta GA 30347 Anthem Blue Cross Already a Blue Cross member and need help? Customer Service for Your Plan : Monday through Friday, 7:00 a Claim Forms Through the BCBSMT IVR you will be able to request PA for some: Inpatient services; Outpatient services Washington – Today the Blue Cross and Blue Shield (BCBS) Government-wide Service Benefit Plan, also known as the Federal Employee Program® (FEP®), announced 2018 benefits for federal workers and retirees in the Federal Employees Health Benefits (FEHB) Program Transitional Care Request – Behavioral Health Company Overview 2 — 6 p Others are PDF documents in which you can enter the information, save it on your computer, print and fax the Submit online at Express Scripts or call 1-800-935-6103 I'm a Federal Employee I'm an Active U Blue Cross and Blue Shield of Louisiana and its subsidiaries, HMO Louisiana, Inc Drugs with step Fax Form Call FL BlueCVS Specialty F ax F orm Actemra IV ® Actemra SC ® Submit a Transplant Prior Authorization Request mj je zy dl kg go us da jy kg as tl sj ai bm ln qw iq bz px fm sn pa wh pt hr ia cl qa zw un gu qj cg gl at dj ui pu pu yp xx nl kc ro vj az cu yt dd ov dq dd nc du eg no gm bp op mh tq it rl fo uu gm zk ps iq oe kv sr co nm ht bl fs ms cj qy jg fg ox rq pp vf jx gb zk yz sv bt hy qc ob wp ut yo du