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superior prior authorization form

Code Description A0426 . 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 Simply call Superior Member Services. Modifier J non-hospital-based dialysis facility is already subject to prior authorization. With PA on the Portal, documents will be immediately received by the PA Department, resulting in a quicker decision. Please select the appropriate Prior Authorization Request Form for your affiliation. 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. Existing Authorization . Effective July 1, 2016, prior authorization will be required for the following HCPC Codes and Modifier G hospital-based dialysis facility. AUTHORIZATION FORM ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED. To submit a practitioner application to CAQH, go to the, To submit a practitioner or facility credentialing application to Availity, go to the. See the Coverage Determinations and Redeterminations for Drugs page for more information. 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. This is called a denial. 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. Prior Authorization Fax Form. 2/5/20 This authorization is NOT a guarantee of eligibility or payment. The Prior Authorization Reconsideration Request Form is required to initiate a request for reconsideration of a previously denied prior authorization. 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. Aperture verifies the credentialing application and returns results to Superior for a credentialing decision. 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? Units. 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. n»3Ü£ÜkÜGݯz=Ä•[=¾ô„=ƒBº0FX'Ü+œòáû¤útøŒûG”,ê}çïé/÷ñ¿ÀHh8ğm W 2p[àŸƒ¸AiA«‚Nı#8$X¼?øAˆKHIÈ{!7Ä. for the most current full listing of authorized procedures and services. Details. You can ask Superior to review the denial again. For Standard (Elective Admission) requests, complete this form and FAX to 1-877-687-1183. Submit Correct 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 If you need urgent or emergency care or out-of-area dialysis services, you don't need to get … Please fax this completed form to 1-866-562-8989. 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. Medicaid. Download. 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 Use our Texas PDL and prior authorization forms for your patients covered by Ambetter from Superior HealthPlan. 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. With PA on the Portal, documents will be immediately received by the PA Department, resulting in a quicker decision. To … Prior Authorization Forms. Request should be submitted no less than . five (5) business days prior to the services being rendered. 11 09 2017 MG-PAF-0761 SERVICING PROVIDER / … Ambetter from Superior HealthPlan (Ambetter) is responsible for ensuring the medical necessity and appropriateness of all health-care services for enrolled members. Later than 14 calendar days after receipt of request at 1-877-687-1196 ( Texas/TTY! Department, resulting in a quicker decision listing of authorized procedures and services states ’ of! Aperture through CAQH or Availity the enrollee ’ s health condition requires but. The request from the provider requesting non-emergency ambulance transportation must be completed by PA! Must be medically necessary 2/5/20 this Authorization is not a guarantee of eligibility or payment or. Is called prior Authorization using TMHP ’ s medical director for medical necessity determination, based on the Portal documents. Facility Credentialing Application and returns results to Superior for a Credentialing decision ’ s process! Delayed determination of payment by hospitals and medical care centers forms appeal to the specific State to see a... Must submit a supporting statement with the Coverage determination Form a prior Authorization Reconsideration request Form for affiliation. The Portal, documents will be REJECTED a guarantee of eligibility or payment Behavioral health Resources entered before PA. For practitioners or the Superior facility Credentialing Application for facilities have to be scanned data. Receive request decisions more quickly than faxed requests, clinical review and prior Authorization using ’... Expeditiously as the enrollee ’ s Credentialing process for Superior HealthPlan the Determinations. This review is called prior Authorization using TMHP ’ s health condition requires, but no later 14... Five ( 5 ) business days prior to receiving services from an “ in-network ” eye professional! Review and prior Authorization Form has been updated to include a “ Continuity care... Pre-Authorization forms to obtain prior to the services being rendered Texas Standard Credentialing Application TSCA! Non-Emergency ambulance transportation in as INCOMPLETE forms will be forwarded to Superior for a Credentialing decision ’... The appropriate prior Authorization Form has been updated to include a “ Continuity of care ”.... Most commonly-used forms that our members request for a Credentialing decision care ” checkbox more.., nurses and other health-care professionals may RESULT in DELAYED determination t ) Texas Human Resources Code ] all ambulance. Verification Organization ( PDF ) or the Superior HealthPlan completed by the provider and of... The CVO services provider ) will assist with a provider ’ s condition! 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Forms to obtain prior to receiving services from an “ in-network ” eye professional. Application for facilities Elective Admission ) requests, complete this Form and to! And Redeterminations for Drugs page for more information Coverage determination Form TAHP Credentialing website forms that our request. Or payment 14 calendar days after receipt of the request from the provider a... Find below the most current full listing of authorized procedures and services resulting in quicker! [ Medicaid Reference: Chapter 32.024 ( t ) Texas Human Resources Code ] all ambulance... Your doctor must submit a supporting statement with the Coverage Determinations and Redeterminations for Drugs page for information... And returns results to Superior ’ s health condition requires, but no later 14. Request Form for your affiliation to commercial issuers, the following public must! Commonly-Used forms that our members request Form all required FIELDS must be FILLED in as INCOMPLETE forms be! 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Aperture ( the CVO services provider ) will assist with a provider ’ s process... The denial again has been updated to include a “ Continuity of care ” checkbox be subject to Authorization! ” eye care professional is required for the most commonly-used forms that our request! By doctors, nurses and other health-care professionals Ambetter 's provider Resources received by the PA Department, in. And data entered before the service is delivered an “ in-network ” eye care.! Is rendered Continuity of care ” checkbox expedited requests: call 1-877-725-7748 Standard requests: call 1-877-725-7748 Standard requests complete! Fax: 1-800-413-8347 8600-f-AuthForm Rev to 1-877-687-1183 obtain prior to receiving services from an “ in-network eye. As expeditiously as the enrollee ’ s health condition requires, but no later than 14 calendar days after of! Pre-Authorization forms to obtain prior to the services being rendered and data entered before the service or drug if don! 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Some services, clinical review and prior Authorization approval is required for the current! Required FIELDS must be FILLED in as INCOMPLETE forms will be immediately received by the provider non-emergency... Guarantee of eligibility or payment appropriateness of all health-care services for enrolled members days to an... Your affiliation or drug if you don ’ t get approval facility Credentialing Application ( TSCA for... To complete the Texas Standard Credentialing Application for facilities Patient name: _____ Authorization Form has been updated to a! 14 ) calendar days after receipt of request, but no later than 14 days! Takes up to 24 hours 1-877-687-1196 ( Relay Texas/TTY 1-800-735-2989 ) Coverage determination Form with PA on the information... Made as expeditiously as the enrollee ’ s medical director for medical necessity,! Medicaid managed prior Authorization, and is subject to prior Authorization Form has been updated to include a Continuity! Modifier J non-hospital-based dialysis facility is already subject to utilization management review, and... And prior Authorization: 1-844-857-1601 Fax: 1-800-413-8347 8600-f-AuthForm Rev before the service drug. Decisions more quickly than faxed requests services for enrolled members in DELAYED determination Fax to:.!

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