1 0 obj Blue Cross Blue Shield of Arizona, Mail Stop A115, P.O. ���I��;,���Y�K��� h��,���3�� �|���(�:������`(��Я��h.T���x[��bh�+@ΑU1�J��ބ�j���.���Oq&0�R�"ߤ2+�_ #�H�˨xg,�N #���nx��ռ�$c2��|��^��V��bXf���\��u��Ũ'u&�N
9��"�h�C��#T1[ڄ����=�b�:J����Z�͔P���k�B=�GG�pr�e�ƒ�J�F��1�H�x%rw�xk�,o4�7���l$�L��hkzJ�q��- w]���DjJ�lf/ё�XK��$���:�C8���2Jl؇Z��]�Ü����9�Zӯ�KĿ9�
s����.�qI�f�r You can refer to the Electronic Provider Access (EPA) FAQs for additional information. Instructions . Prior Authorization, preauthorization, prospective review, prenotification or prior approval refer to the prior assessment that proposed services are medically necessary, appropriate and a covered medical expense of the member/participant contract. For Prescription Drugs . %���� <>stream Submit medical drug prior authorization requests online . REQUIRED: Office notes, labs, and medical testing relevant to the request that show medical justification are required. For Medicaid to reimburse the provider in this situation, MDHHS requires that the provider obtain authorization for these services before the service is rendered.The PA tab allows Fee for Service providers to submit single PA requests through the online web portal. The complete form must be faxed to PerformRX at 1-855-811-9326 or mailed to PerformRX at the address on the form. Obesity surgery Services require authorization. What is Prior Authorization. Pre-certification. �V�������� � KPX����D��/�����E���|�8J���r8NMaV��[+P�S�~lG�dT�E� �H
ZgK?E�P�����������Wu*��TB%�W�ê=4������J��~f���=ř����1�A���f�N���%�? ��)}�ױ��jMc�yG��+M�î�N�;.`Vl��o S�J�[S� v�H$[�G"���'�1¥�����]J�$q�Yy)&��C��g"��ؙ�m�����T�ъ�N" Pharmacy Prior Authorization Request Form Do not copy for future use. The Michigan Department of Health and Human Services (MDHHS) There may be occasions when a beneficiary requires services beyond those ordinarily covered by Medicaid or needs a service that requires prior authorization (PA). Step 2 – Begin by entering the date at the top of the page. This includes prior authorization for high-tech imaging services. As part of our efforts to make the prior authorization (PA) process more efficient, we’re encouraging prescribers register and use our Webbased system when prescribing medical - drugs for commercial members. submit authorization requests using the Blue Cross Complete Medication Prior Authorization Request form, which is available at mibluecrosscomplete.com on the Pharmacy Benefits page, under Prior authorization. Prior Authorization. Preferred Drug List – List of pre-approved drugs by the State. Important: Please read all instructions below before completing FIS 2288. @J6�[P�Q�x�+&�v,CȖ�L&��#v؋�E�vB���O�W�VM�rB�x�����Q`�f�c���@�[��˒T��$�W���
*�fD���clf�!�7��P������q���?�M�g���t��oaځD����)6Bt�^����+/�s�B��3ap����-�J-{+�ӊF���TI�]����Уv���;;L�L�����
/� h!��#*�qig4��sx��iؒ�R`V�>�a��
ϵ��?a�߯��� �����}n��u��[aeX+�X���Z�1 Also known as preauthorization or pre-notification, pre-certification confirms that a physicians’ plan of treatment meets medical necessity criteria under the applicable health benefit plan. Any provider may request PA, however, the provider NPI entered the servicing provider field must represent the provider who will be rendering the service. Section 2212c of Public Act 218 of 1956, MCL 500.2212c, requires the use of a standard prior authorization form when a policy, certificate or contract requires prior authorization for prescription drug benefits. Once the PA request is successfully entered, the provider receives a tracking number. An error message is returned to the user if the information is incorrect. Forms are updated frequently. CHAMPS validates both beneficiary and provider information. %PDF-1.6 If the request is approved by MDHHS, this tracking number becomes the prior authorization number to use for billing purposes.needed to access the PA tab: CHAMPS Full Access, CHAMPS Limited Access, Prior Authorization AccessTo access a resource click on the preferred file hyperlink. Once completed, this form must be faxed to the correct directory. There may be occasions when a beneficiary requires services beyond those ordinarily covered by Medicaid or needs a service that requires prior authorization (PA). Requests must … A prior authorization is not a guarantee of benefits or payment. How to Write. {]2��tQY�$]�Z�YX�K�6 ����}>�;���g���*��S
4��ŭ������ Step 1 – Download the PDF version of the Michigan Medicaid prior authorization form and open it using either Adobe Acrobat or Microsoft Word. For Medicaid to reimburse the provider in this situation, MDHHS requires that the provider obtain authorization for these services before the service is rendered. Michigan Prior Authorization Request Form .