A prior authorization cover sheet is typically a standard form that healthcare providers use to request prior authorization for medical services or treatments.
The process starts with the healthcare provider submitting a prior authorization request to the patient's insurance company.
The request must include relevant information such as the patient's name, date of birth, and policy number.
This information helps the insurance company to verify the patient's coverage and process the request efficiently.
Prior Authorization Process
The prior authorization process can be lengthy, often taking 2-5 business days to complete.
To initiate the process, a provider must submit a prior authorization request to the patient's insurance plan, which typically involves completing a prior authorization cover sheet.
The cover sheet requires specific information, including the patient's name, date of birth, and insurance ID number, as well as the medication or treatment being requested.
The requesting provider must also specify the diagnosis and medical necessity for the treatment, which helps the insurance plan determine whether the request is approved.
Forms and Requirements
To get started with the prior authorization process, you'll need to access the right forms. You can find them on the Carolina Complete Health website.
The Prior Authorization Fax Form is available in two versions: one for the CCH Standard Plan and another for the Trillium Physical Health Tailored Plan. Both can be downloaded as PDFs.
If you're unsure which form to use, refer to the Prior Authorization Tip Sheet (also a PDF) for guidance.
To fax your completed forms, you'll need to use a specific number. The Standard Plan CCH Fax Number Reference Guide lists the fax numbers for different types of documents.
Here are the fax numbers and corresponding document types:
- Fax Number: 833-238-7690, Document Type: Carolina Complete Health Medicaid Face Sheets
- Fax Number: 833-238-7691, Document Type: Carolina Complete Health Medicaid Assessments
- Fax Number: 833-238-7692, Document Type: Carolina Complete Health Medicaid Inpatient Requests
- Fax Number: 833-238-7693, Document Type: Carolina Complete Health Medicaid Medical Records
- Fax Number: 833-238-7694, Document Type: Carolina Complete Health Medicaid Prior Authorization
- Fax Number: 844-975-1325, Document Type: Carolina Complete Health Medicaid Census Reports
- Fax Number: 833-596-2768, Document Type: Carolina Complete Health Inpatient Behavioral Health PA
- Fax Number: 833-596-2769, Document Type: Carolina Complete Health Outpatient Behavioral Health PA
Retrospective Authorization Review
Retrospective Authorization Review is an important part of the Prior Authorization Process. It involves a review of a service or treatment that has already been provided to determine if it was necessary and meets the requirements.
There is a guide available for providers to request a Retrospective Authorization Review, which can be found in the Provider Guide: Retrospective Authorization Review Request (PDF).
Frequently Asked Questions
What information is included in a prior authorization?
Prior authorization typically includes information about the medical necessity of a treatment, such as why a more expensive option is needed over a less expensive alternative. This may involve verifying the accuracy of supporting documentation and justifying the chosen treatment.
Can you bill for prior authorization?
Yes, you can bill for prior authorization using specific CPT codes, which cover time spent completing authorizations for medications and orders. These codes allow you to claim reimbursement for staff time spent on prior authorization tasks.
Sources
- https://www.blueshieldca.com/en/provider/authorizations/authorization-forms
- https://www.azahcccs.gov/PlansProviders/RatesAndBilling/FFS/priorauthorizationforms.html
- https://network.carolinacompletehealth.com/resources/prior-authorization.html
- https://www.bcbsnd.com/providers/news-resources/forms-documents
- https://www.michigan.gov/mdhhs/doing-business/providers/providers/medicaid/policyforms/medicaid-provider-forms-and-other-resources
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