Phcs Prior Authorization Process and Requirements

To initiate the prior authorization process with PHCS, you'll need to submit a request through their online portal or by phone.

The PHCS prior authorization process typically takes 2-4 business days to complete once all required documentation is received.

You'll need to provide detailed information about the patient's diagnosis, treatment plan, and medical history to support the request.

PHCS requires a valid medical necessity justification for each service or medication being requested.

To submit authorizations to our partners, you'll need to know who to contact and how to get the process started. For behavioral health, Optum is the partner to reach out to at 844-451-3520 or 844-451-3518.

You can also visit the Optum Provider Express Portal for more information and to submit prior authorization requests. For specialty drugs, Specialty Fusion reviews requests through their online prior authorization tool, which can be accessed through the Provider portal. If you need to submit a request via fax, you can use one of the Standard Prior Authorization forms and fax it to 855-540-3693.

Here's a quick rundown of the key contacts and resources for submitting authorizations:

If you need to submit authorizations to our partners, there are several ways to do so.

For behavioral health, you can contact Optum at 844-451-3520 or visit the Optum Provider Express Portal for more information and to submit prior authorization requests.

Specialty drugs require prior authorization, which can be submitted through the Specialty Fusion online prior authorization tool or by faxing a Standard Prior Authorization form to 855-540-3693.

You can also reach out to Specialty Fusion customer service at 877-519-1908 for more information.

Optum Rx manages pharmacy benefits for Mass General Brigham Health Plans with prescription drug coverage, and you can contact them at 800-711-4555 or fax them at 844-403-1029.

CareCentrix handles sleep management, and you can contact them at 866-827-5861 or visit their portal for more information and to submit prior authorization requests.

EviCore manages molecular and genetic testing, and you can contact them at 888-693-3211 or visit their dedicated Mass General Brigham Health Plan resource page for more information and to submit prior authorization requests.

Here's a list of some of the partners and their contact information:

Note that prior authorization is required for certain services, and you should check with the partner for specific requirements.

To submit pharmacy services, you'll need to complete the required forms. The Cell and Gene Attestation form is necessary for Hemophilia A and Hemophilia B.

You can access the CMS standard format/CCD creator online, which will help you create a standardized format for your submissions.

If you're requesting a new drug, you'll need to fill out the New Drug Request form.

To determine the requirements for your submission, you need to consider a few key factors. First, check if the code or service requires prior authorization by reviewing the provider billing guides and fee schedules. This will help you understand the specific requirements for your submission.

It's also important to note that HCA's authorization services don't consider National Correct Coding Initiative (NCCI) guidelines, so make sure your office checks those guidelines prior to submission.

If you're billing for an Environmental Protection Agency (EPA) number, keep in mind that you must use the EPA number on your claim. You also need to provide documentation to the agency showing how the client's condition meets all the criteria for EPA, upon request.

Here are the key requirements to keep in mind:

Remember, inadvertently approved authorizations don't guarantee claims payment, and the agency may recoup any payment made to a provider if the required process isn't followed.

If you need to submit supporting documents to an existing authorization, there are specific steps to follow. For general PA requests, use the cover sheet provided by HCA when submitting supporting documents to an already existing authorization.

You can find step-by-step instructions for adding supporting documents to an existing request in pend or approve/hold status by viewing our guide.

If you're submitting drugs through the pharmacy point-of-sale (POS) system, a barcode cover sheet is not required. You can submit supporting documentation by faxing the form as the first page followed by the supporting documentation, or by faxing a completed Pharmacy Information Authorization (HCA 13-835A) form as the first page followed by supporting documentation.

Here are the specific faxing options for pharmacy POS system submissions:

Electronic submission is a convenient and efficient way to submit prior authorization requests. You can submit requests to various partners, including Optum, Specialty Fusion, Optum Rx, CareCentrix, and EviCore.

Optum is the partner for behavioral health, and you can submit requests through their Provider Express Portal, phone, or fax. Specialty Fusion handles specialty drugs, and you can use their online prior authorization tool or fax a standard prior authorization form.

Optum Rx manages pharmacy benefits, and you can submit requests by phone or fax. CareCentrix is the partner for sleep management, and you can submit requests through their portal or phone. EviCore handles molecular and genetic testing, and you can submit requests through their portal or phone.

Here's a list of the partners and their contact information:

Pre-certification is a crucial step for inpatient and outpatient procedures or surgeries performed in a facility. It requires a 5-7 day advance notice to the insurance provider.

All inpatient and outpatient procedures or surgeries need pre-certification and authorization, including behavioral health and chemical dependency services. This process also applies to home healthcare and hospice care.

Pre-certification involves calling Lucent Health to confirm eligibility and benefits at 877-214-2129. A list of procedures requiring pre-certification can be found on the back of your ID card.

Your provider will need to contact Narus Health to initiate the pre-certification process. They will collect information such as your name, member ID number, physician's name and contact information, type of procedure, and expected date of procedure.

Narus Health will coordinate with the plan on your behalf and notify you of the procedure's status. This ensures that the necessary pre-service negotiations are conducted, if needed.