n»3Ü£ÜkÜGݯz=Ä•[=¾ô„=ƒBº0FX'Ü+œòáû¤útøŒûG”,ê}çïé/÷ñ¿ÀHh8ğm W 2p[àŸƒ¸AiA«‚Nı#8$X¼?øAˆKHIÈ{!7Ä. SUPERIOR HEALTH PLAN MEDICAID/FOSTER CARE/CHIP INSTRUCTIONS FOR OBTAINING PRE-AUTHORIZATION FOR OPHTHALMOLOGY SERVICES Envolve Vision of Texas, Inc. (Envolve Vision) requires all services listed below be authorized prior to the services being rendered. MEMBER INFORMATION. Code Description A0426 . Superior STAR+PLUS MMP may not cover the service or drug if you don’t get approval. Existing Authorization . 11 09 2017 MG-PAF-0761 SERVICING PROVIDER / … Date of Birth. [Medicaid Reference: Chapter 32.024(t) Texas Human Resources Code] All non-emergency ambulance transportation must be medically necessary. Fax requests have to be scanned and data entered before the PA Department receives them, which takes up to 24 hours. Units . Medicaid. … Physician information Patient name: _____ Urgent requests - I certify this request is urgent and medically necessary to … If you need help understanding the language being spoken, Superior has people who can help you on the phone or can go with you to a medical appointment. PDF; Size: 41 KB. Updated: 2/2018 Purpose. Superior requires services be approved before the service is rendered. Patient information 2. Prior Authorization Form Submit your prior authorization using TMHP’s PA on the Portal and receive request decisions more quickly than faxed requests. For Standard requests, complete this form and FAX to 1-877-687-1183. Aperture verifies the credentialing application and returns results to Superior for a credentialing decision. AUTHORIZATION FORM Expedited requests: Call 1-877-935-8024 Standard Requests: Fax to 1-877-687-1183 Request for additional units. Per Medicare guidelines, Superior Vision has 3–14 business days to get an authorization to the provider. Online Prior Authorization Form for all Plans. Member ID * Last Name, First. Simply call Superior Member Services. Online Prior Authorization Form for all Plans. A Prior Authorization and/or a Referral is required for the following covered services in plan year 2020: Authorization Required Referral Required . Expedited requests: Call 1-877-725-7748 Standard Requests: Fax to 1-877-689-1055 Rev. Date of request: Request to modify existing authorization (include authorization number): Details of modification: To the best of your knowledge this medication is: New therapy Continuation of therapy (approximate date therapy initiated): Expedited/Urgent Review Requested. There are no vouchers or pre-authorization forms to obtain prior to receiving services from an “in-network” eye care professional. CCP Prior Authorization Request Form F00012 Page 1 of 3 Revised: 10/15/2016 | Effective Date: 12/10/2016 Submit your prior authorization using TMHP’s PA on the Portal and receive request decisions more quickly than faxed requests. Superior HealthPlan Prior Authorization Form Format. five (5) business days prior to the services being rendered. About CoverMyMeds LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION. Determination made as expeditiously as the enrollee’s health condition requires, but no later than 14 calendar days after the receipt of request. Please fax this completed form to 1-866-562-8989. Download. Once the completed application is processed through Availity or CAQH, Aperture automatically retrieves the submitted information and performs the primary source verifications of submitted credentials. Instructions. This is called a denial. If a prior authorization request cannot be approved based on medical necessity, you will receive a letter with the reason why the prior authorization request was not approved. They use this to confirm whether certain drugs and procedures prescribed to a patient by the doctor are covered under his medical insurance policy or not. Units. If you do not see a form you need, or if you have a question, please contact our Customer Service Center 24 hours a day, 7 days a week, 365 days a year at (800) 460-8988. This review is called prior authorization, and is made by doctors, nurses and other health-care professionals. COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. The Medicaid prior authorization forms appeal to the specific State to see if a drug is approved under their coverage. Skip to Main Content. Prior Authorization Forms. Existing Authorization . Download the free version of Adobe Reader. Need health insurance? This form is to be completed by the patient’s medical office to see if he or she qualifies under their specific diagnosis and why the drug should be used over another type of medication. Existing Authorization. Please select the appropriate Prior Authorization Request Form for your affiliation. Please refer to SuperiorHealthPlan.com . Does Superior Vision require that an employee obtain an authorization form or a voucher prior to being able to receive services at an “in-network” eye care professional? effective-january-1-2021--ambetter-clinician-administered-drug-prior-authorization-update Ambetter Clinician Administered Drug Prior Authorization Update Call us at 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989). Submit Correct Prior Authorization Forms. Please find below the most commonly-used forms that our members request. If we grant your request, we must give you a decision no later than 24 hours after we get your doctor’s supporting statement. Prior Authorization Fax Form Fax to: 855-537-3447. Prior Authorization Request Forms are available for download below. Use our Texas PDL and prior authorization forms for your patients covered by Ambetter from Superior HealthPlan. To submit a practitioner application to CAQH, go to the, To submit a practitioner or facility credentialing application to Availity, go to the. Providers are required to complete the Texas Standard Credentialing Application (TSCA) for practitioners or the Superior Facility Credentialing Application for facilities. Note that an authorization is not a guarantee of payment and is subject to utilization management review, benefits and eligibility. Health Details: Submit Correct Prior Authorization Forms.Date: 05/21/20 As a reminder, Superior HealthPlan launched new inpatient and outpatient forms for requesting prior authorization for medical and behavioral health services, with updated fax numbers listed on the forms on February 22, 2020. superior medicaid prior authorization form Ambetter from Superior HealthPlan (Ambetter) is responsible for ensuring the medical necessity and appropriateness of all health-care services for enrolled members. Request should be submitted no less than . Prior Authorization Forms. Growth Hormone Therapy-Pediatric Prior Authorization Form/ Prescription - Envolve Author: Envolve Pharmacy Solutions Subject: Growth Hormone Therapy-Pediatric Prior Authorization Form/ Prescription Keywords: patient, information, insurance, physician, primary diagnosis, clinical, prescription Created Date: 12/12/2014 4:26:22 PM Prior authorization means that you must get approval from Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) before you can get a specific service or drug or see an out-of-network provider. This is called an appeal. The Superior HealthPlan Request for Prior Authorization Form has been updated to include a “Continuity of Care” checkbox. Credentialing documents are submitted to Aperture through CAQH or Availity. You can also request any materials on this website in another format, such as large print, braille, CD or in another language. You will need Adobe Reader to open PDFs on this site. Any services rendered beyond those authorized or outside approval dates will be subject to denial of payment. Provider Help Desk: 1-800-454-3730 1. Health Details: Submit Correct Prior Authorization Forms.Date: 05/21/20 As a reminder, Superior HealthPlan launched new inpatient and outpatient forms for requesting prior authorization for medical and behavioral health services, with updated fax numbers listed on the forms on February 22, 2020. superior auth form for texas Request Network Participation, Non-Contracted Providers Only, Add a Provider to an Existing Group Contract, Add a Practice Location to an Existing Contract, Practice Improvement Resource Center (PIRC), Updating Provider Demographic Information, Acknowledgement of Consenting Person/Surrogate Decision-Maker (PDF), Dental Therapy Under General Anesthesia (PDF), Medicare Dental Therapy Under General Anesthesia (PDF), Medical Necessity and Level of Care Assessment Physician’s Signature (PDF), Medical Necessity and Level of Care Assessment Physician's Signature FAQs (STAR+PLUS and MMP) (PDF), Notification of Pregnancy (NOP) Incentive Program Details (PDF), Nursing Facility Service Notification Form (PDF), Physician Certification (2601 Form) (PDF), Physician Certification (2601 Form) FAQs (STAR Kids and STAR Health) (PDF), Primary Care Provider (PCP) Change Request Form (PDF), Sterilization Consent Form Instructions - English (PDF), Tuberculosis Screening and Education Tool - English and Spanish (PDF), Vision Care Eyeglass Patient Certification - English and Spanish (PDF), 2020 Inpatient Medicaid Authorization Form (PDF), 2020 Outpatient Medicaid Authorization Form (PDF), 2020-2021 Synagis® Season – Addendum Prior Authorization Form (PDF), 2020-2021 Synagis® Season – Prior Authorization Form (PDF), Allergen Extracts Prior Authorization Request (PDF), Attestation Form for Allergy and Immunology Therapy (PDF), Biopharmacy Outpatient Prior Authorization Form (J-code products) (PDF), Discharge Planning Prior Authorization Request (PDF), Hepatitis C – Initial  Prior Authorization Request (PDF), Hepetitis C Treatment - Prescriber Certification (PDF), LTSS and Pharmacy Prior Authorization Request Form (PDF), Non-Preferred VDP Prior Authorization Request (PDF), PCSK9 Inhibitor Prior Authorization Request (PDF), Provider Statement of Need Frequently Asked Questions (PDF), Provider Statement of Need – STAR+PLUS and STAR+PLUS MMP (PDF), Provider Statement of Need – STAR Kids and STAR Health (PDF), Texas Standard Prior Authorization Request (PDF), Texas Standard Pharmacy Prior Authorization Request (PDF), TMHP CCP Prior Authorization Private Duty Nursing 6-Month Authorization Form (PDF), TAHP Introduction to the Texas Credentialing Verification Organization (PDF), Behavioral Health Disclosure of Ownership and Control Interest Statement (PDF), Behavioral Health Facility and Ancillary Credentialing Application (PDF), Behavioral Health Provider Specialty Profile (PDF), Central Registry Check Request for Abuse/Neglect (PDF), Individual and Group Provider Credentialing Application (PDF), 2020 Inpatient MMP Authorization Form (PDF), 2020 Outpatient MMP Authorization Form (PDF), LTSS and Pharmacy Inpatient Prior Authorization Form (PDF), LTSS and Pharmacy Outpatient Prior Authorization Form (PDF), Medicare Part B Prior Authorization List (PDF), Prior Authorization Form Instructions (PDF), STAR+PLUS MMP Prior Authorization List (PDF), 835 Claim Adjustment Reason Codes Crosswalk to EX Codes (PDF), EDI Audit Report Claim Rejection Codes (PDF), 2020 Inpatient Medicare Authorization Fax Form (PDF), 2020 Outpatient Medicare Authorization Fax Form (PDF), LTSS and Pharmacy Inpatient Prior Authorization Fax Form (PDF), LTSS and Pharmacy Outpatient Prior Authorization Fax Form (PDF), HMO Drug Coverage Determination Form (PDF), HMO SNP Drug Coverage Determination Form (PDF), Provider Attestation Statement (Administration Only) (PDF), Provider Attestation Statement (Clinically Trained) (PDF). The prior authorization request will be forwarded to Superior’s medical director for medical necessity determination, based on the clinical information available. In addition to commercial issuers, the following public issuers must accept the form: Medicaid, the Medicaid managed Superior requires the utilization of the statewide Texas Credentialing Alliance and the contracted Credentialing Verification Organization (CVO) as part of the credentialing and re-credentialing process. 2/5/20 This authorization is NOT a guarantee of eligibility or payment. Provider Instructions for Non-emergency Ambulance Prior Authorization Request Form This form must be completed by the provider requesting non-emergency ambulance transportation. For some services, clinical review and prior authorization approval is required before the service is delivered. Aperture (the CVO services provider) will assist with a provider’s credentialing process for Superior HealthPlan. Submit Correct Prior Authorization Forms. This form is generally used by hospitals and medical care centers. You can ask Superior to review the denial again. All services are … To request prior authorization, please complete the Authorization Request Form and, along with the medical record in support of the request, fax it to Superior Vision at 1-855-313-3106 or send via secure email to ecs@superiorvision.com. Your doctor must submit a supporting statement with the Coverage Determination form. Prior Authorization of Benefits Form CONTAINS CONFIDENTIAL PATIENT INFORMATION Complete form in its entirety and fax to: Prior Authorization of Benefits Center at 1-844-512-9004. Modifier G is a new requirement. Effective July 1, 2016, prior authorization will be required for the following HCPC Codes and Modifier G hospital-based dialysis facility. 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. File Format. Details. Determination made as expeditiously as the enrollee’s health condition requires, but no later than 14 calendar days after receipt of request. AUTHORIZATION FORM ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED. Start Date* End Date* TMHP CCP Prior Authorization Private Duty Nursing 6-Month Authorization Form (PDF) Credentialing Verification Organization (CVO) Superior requires the utilization of the statewide Texas Credentialing Alliance and the contracted Credentialing Verification Organization (CVO) as part of the credentialing and re-credentialing process. To locate Behavioral Health forms, please visit Superior's Behavioral Health Resources. With PA on the Portal, documents will be immediately received by the PA Department, resulting in a quicker decision. Modifier J non-hospital-based dialysis facility is already subject to prior authorization. This process will bise completed within fourteen (14) calendar days after receipt of the request from the provider. Authorization Request Form Attn: Intake Processing Unit Phone: 1-844-857-1601 Fax: 1-800-413-8347 8600-f-AuthForm Rev. The form provides a brief description of the steps for reconsideration and is … Prescription prior authorization forms are used by physicians who wish to request insurance coverage for non-preferred prescriptions.A non-preferred drug is a drug that is not listed on the Preferred Drug List (PDL) of a given insurance provider or State. Superior HealthPlan Quick Reference Guide for Imaging Providers - Updated 4/2/18* Superior Healthplan Provider FAQ; Superior HealthPlan / NIA CPT Code Matrix ; Superior HealthPlan Provider Education Presentation Superior HealthPlan Prior Authorization Checklist (non-cardiac) Superior HealthPlan Prior Authorization Request Form Medicaid. Request for additional units. See the Coverage Determinations and Redeterminations for Drugs page for more information. for the most current full listing of authorized procedures and services. Åî”İ#{¾}´}…ı€ı§ö¸‘j‡‡ÏşŠ™c1X6„�Æfm“��;'_9 œr�:œ8İq¦:‹�ËœœO:ϸ8¸¤¹´¸ìu¹éJq»–»nv=ëúÌMà–ï¶ÊmÜí¾ÀR 4 ö PRIOR AUTHORIZATION FORM Complete and Fax to: 800-690-7030 Behavioral Health Requests/Medical Records: Fax 855-772-7079 Request for additional units. The Prior Authorization Reconsideration Request Form is required to initiate a request for reconsideration of a previously denied prior authorization. Units (MMDDYYYY) Standard and Urgent Pre-Service Requests - Determination within 3 calendar days (72 hours) of receiving the request * INDICATES REQUIRED FIELD. Our electronic prior authorization (ePA) solution is HIPAA-compliant and available for all plans and all medications at no cost to providers and their staff. AUTHORIZATION FORM Expedited requests: Call 1-877-935-8024 Standard/Concurrent Requests: Fax 1-877-687-1183. Texas Medicaid, CSHCN Services Program, and Medicare have similar … To … Prior Authorization Fax Form. If you need urgent or emergency care or out-of-area dialysis services, you don't need to get … Superior Health Plan's Preferred Method for Prior Authorization Requests CoverMyMeds is the fastest and easiest way to review, complete and track PA requests. To locate Ambetter from Superior HealthPlan Provider Forms, please visit Ambetter's Provider Resources. Policies may vary between each states’ department of health but the process more or less remains the same. 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