Va medicaid prior authorization form XOLAIR® (omalizumab) Prior Authorization (PA) Form Virginia | HealthKeepers, Inc. 3859 and a Important Notes: Preauthorization for medical necessity does not guarantee payment. gov/bms/Pharmacy/Pages/default. INTRODUCTION Service authorization (Srv Auth) is the process to approve specific services for an enrolled Medicaid, FAMIS Plus or FAMIS individual by a Medicaid enrolled provider prior to service delivery and reimbursement. HNS Potential Provider FormsExpand sub pages Commonwealth Coordinated Care Plus (CCC Plus) Expand sub pages Provider Enrollment & Revalidation Expand sub pages ARTS Credentialing and Resources for Providers Nursing Facility Quality Improvement Program (NFQIP) Jun 17, 2025 · Prior authorization forms for Virginia Community Plan healthcare providers requesting authorization for specific drugs. Date: Provider return fax: Please submit all appropriate clinical information, provider contact information and any other required documents with this form to support your request. com/providers/va/medicaid/resources/forms. wv. | Anthem HealthKeepers Plus Medicaid products If the following information is not complete, correct, or legible, the PA process can be delayed. Fax completed form, along with all necessary clinical information to support medical necessity review request to Acentra Health at 512- 975-7642. If the following information is not complete, correct, or legible, the PA process can be delayed. See the DHB Clinical Coverage Policy Website for additional information. Self-funded plans are excluded and default to the group plan document. Sign, print, and download this PDF at PrintFriendly. Atrezzo Next Generation (ANG) supports the entire WVCHIP Medical process for clinical determination of services. Describe person-centered, recovery-oriented, trauma-informed mental health treatment goals as they relate to requested treatment. Member information Last name: Obtaining authorization does not guarantee payment. For Medicare private fee-for A Certificate of Medical Necessity (CMN), DMAS 352 form, will be completed by the practitioner or DME provider. Prior authorization (PA) is required for some medications. Learn more about what services require prior authorization. Download authorization forms from: molinahealthcare. Broad Street Glen Allen, VA 23060 Intrauterine Insemination Some health care services require prior authorization or preapproval first. PHYSICAL HEALTH STANDARD PRIOR AUTHORIZATION REQUEST FORM Aetna Better Health of Virginia 9881 Mayland Drive Richmond, VA 23233 REGISTRATION ON ATTREZO IS REQUIRED TO SUBMIT PRIOR AUTHORIZATION REQUESTS WHETHER BY FAX OR ELECTRONICALLY. Use one form per member please. Requests for service authorization (SA) must include patient name, Medicaid ID#, and drug name. Member Last Name: Enter the Member’s last name exactly as it appears on the Medicaid card. West Virginia Medicaid contracts with the West Virginia University School of Pharmacy Rational Drug Therapy Program (RDTP) for prior authorization services. Pharmacy 10-Digit NPI# Confidentiality Notice: This document contains confidential health information that is protected by law. Browse commonly requested forms to find and download the one you need for various topics including pharmacy, enrollment, claims and more in Virginia. Please review the essential Medicaid Bulletins regarding the transition to Acentra Health, as well as information about provider Prior authorization is required for some out-of-network providers, outpatient care and planned hospital admissions. If you need authorization for any of the following services, please select the link below: Jun 14, 2024 · The West Virginia Do Not Resuscitate (DNR) order form informs medical professionals of an individual's desire not to receive CPR if they experience cardiac or respiratory failure. The order must be issued to the patient by a licensed physician who has established a relationship with the individual. Oct 1, 2024 · Synagis® requires service authorization (SA) for reimbursement through the Virginia Medicaid Agency. COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES Service Authorization (SA) Form ANTIPSYCHOTICS IN CHILDREN YOUNGER THAN 18 YEARS OLD If the following information is not complete, correct, or legible, the SA process can be delayed. Prior authorization requests can be made by faxing the appropriate PA form to 1-800-531-7787 or by electronic submission through the MediWeb Portal. aspx Rational Drug Therapy Program WVU School of Pharmacy Services requiring prior authorization Providers are responsible for verifying prior authorization requirements before services are rendered. completed prior authorization request form to 855-799-2553 or submit Electronic Prior Authorization CoverMyMeds® or SureScripts. Please review prior authorization requirements below and check plan benefits. Only covered services are eligible for reimbursement. Member Full Name: Medicaid #: December 2021: Applied Behavior Analysis_Initial Authorization 5 E. HealthKeepers Inc. Our solution integrates into your workflow to reduce delays, speed up determinations and help patients get their medications faster. REGISTRATION ON ATTREZO IS REQUIRED TO SUBMIT PRIOR AUTHORIZATION REQUESTS WHETHER BY FAX OR ELECTRONICALLY. Search the MES Website (New!) Health care professionals can access forms for UnitedHealthcare plans, including commercial, Medicaid, Medicare and Exchange plans in one convenient location. Service Authorization Form Short-Acting Opioids he following information is no complete, correct, or legible, the SA process can be delayed. Scientific evidence is lacking for the benefits of opioids for treatment of chronic pain. Sep 30, 2025 · Resources HCA-12A Prior Authorization form HCA-13A Prior Authorization Attachment Form Cover Sheet Sep 30, 2025 · Resources HCA-12A Prior Authorization form HCA-13A Prior Authorization Attachment Form Cover Sheet Jan 1, 2025 · This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Virginia/Virginia Cardinal Care health care professionals providing inpatient and outpatient services. The Louisiana Department of Health protects and promotes health and ensures access to medical, preventive and rehabilitative services for all citizens of the State of Louisiana. dhhr. for members enrolled in the Anthem HealthKeepers Plus plan using the current corresponding DMAS-mandated forms that are posted on the DMAS website: MEDICAL PRIOR AUTHORIZATION/STEP-EDIT REQUEST* Directions: The prescribing physician must sign and clearly print name (preprinted stamps not valid) on this request. Service Authorization Form Long-Acting Opioids he following information is not complete, correct, or legible, the SA process can be delayed. Forms & Downloads The forms and reference file downloads found below represent more important/popular downloads available from the MES portal. SCREENING CERTIFICATION - This authorization is appropriate to adequately meet the Individual's needs and assures that all other resources have been explored prior to Medicaid authorization for this Individual. If you need authorization for any of the following services, please select the link below: C10645-A Effective: 07/31/2025 Page 4 of 5 AETNA BETTER HEALTH® OF VIRGINIA REQUEST FORM: Weight-Loss Management Member’s Last Name: Member’s First Name: All approvals are subject to the criteria on this form. The form that must be filled out to submit a prior authorization request will be changing. Atrezzo Next Generation (ANG) for Medical Services-Provider Portal Beginning February 1, 2022, entities seeking approval for medical services will utilize Atrezzo Next Generation (ANG) to submit prior authorization requests. You may also request a prior authorization (PA) by contacting Acentra Health’s Customer Service Department at 800-634-4832. ROUTINE PDL If the following information is not complete, correct, or legible, the SA process can be delayed. For Virginia CCC Plus or Medallion 4. You may fax the Fee For Service Prior Authorization Request Form to the AHCCCS FFS Prior Authorization Unit to request authorization, or you may use AHCCCS Online to enter a pended authorization request online, 24 hours a day/7 days a week. Prior to starting MHSS services the individual has a prescription for anti-psychotic, mood stabilizing, or antidepressant medications within 12 months prior to the assessment date unless there is signed documentation from a physician or other licensed prescribing practitioner indicating that medications are contraindicated. Phone: 800-555-2546 Fax: 877-486-2621 Humana manages the pharmacy drug benefit for your patient listed below. 0, see specific section below. Preferred stimulants/ADHD medications for individuals 4 to 17 years of age do not require Service Authorization. Prior Authorization Request Form Select the radio button of the entity that must authorize the service. Download Word to open and read Word documents (. The plan retains the right to review benefit limitations and exclusions, beneficiary eligibility on the date of the service, correct coding, billing practices and whether the service was provided in the most appropriate and cost-effective setting of care. Some services do not require Srv Auth and some may begin prior to requesting authorization Prior authorization information and forms for providers. aspx Fax completed forms to appropriate number below. SA Forms | MESService Authorization Related Forms Here's what you need to know about referrals, preapprovals, and prior authorization requirements for Anthem Medicaid in Virginia. Providers, get materials and forms such as the provider manual and commonly used forms. The fax number for the prior authorization process will remain the same. Introduction Service authorization is the process to approve specific services for an enrolled Medicaid, FAMIS Plus or FAMIS individual by a Medicaid enrolled provider prior to service delivery and reimbursement. You can use the Prior Authorization Lookup Tool or reference the provider manual to determine if authorization is needed. Provider resources Find the documents and resources you need to provide quality care for Humana Healthy Horizons ® in Virginia members. Please verify benefit coverage prior to rendering services. Inpatient services and non-participating Anthem HealthKeepers Plus providers always require prior authorization. The Department of Medical Assistance Services contracts with Acentra Health (formerly known as Kepro) to handle the service authorization process for Medicaid, Family Access to Medical Insurance Security (FAMIS) and FAMIS Plus clients in the fee-for-service programs. The completed form may be: FAXED TO 800-932-6651, phoned to 800-932-6648, or mailed to: Magellan Medicaid Administration / ATTN: MAP 11013 W. Out-of-State providers are held to the same service authorization processing rules as in state providers and must be enrolled with Virginia Medicaid prior to submitting a request for out-of-state services to KEPRO. View the West Virginia Medicaid Drug Prior Authorization Form in our collection of PDFs. The authorization for long-term care can be made regardless of whether the Individual has been determined Medicaid-eligible, but placement may not be available until the provider is assured of the Individual’s Medicaid status. Requests for service authorization (SA) must include patient name, Medicaid ID#, drug name, and appropriate clinical information to support the request on the basis of medical necessity. Fax to 1-800-264-6128. Sign InDownload Adobe Acrobat Reader to open and read PDF documents from this site. Referrals for out-of-network shall be requested by an enrolled West Virginia Medicaid provider with required documentation of the established criteria as noted below. Fax and phone requests are not accepted. Opioids can provide short-term benefits for moderate to severe acute p May 5, 2025 · Downloadable forms to submit for medical prior authorizations for Sentara Health Plans providers. WEIGHT-LOSS MANAGEMENT If the following information is not complete, correct, or legible, the SA process can be delayed. Appropriate clinical information to support the request on the basis of medical necessity must be submitted. Our published forms are currently under review, and going forward we plan on a better way to categorize the forms, making it easier to find the form you need. Refer to Molina Healthcare's (M's) provider website or prior authorization (PA) look-up tool/matrix for specific codes that require authorization. Some services do not require service authorization and some may begin prior to requesting authorization. Sentara Medical Group Authorization to Disclose Protected Health Information If you want to have a medical record transferred from another doctor’s office to your new Sentara Medical Group office, please complete this form. Please use one form per member: completed prior authorization request form to 855-799-2553 or submit Electronic Prior Authorization CoverMyMeds® or SureScripts. Looking for a form that isn’t listed? Feel free to contact Provider Services for assistance. If no drug-specific form is available, please use the following general form. The practitioner should refer the member to a DME provider with an order for the CGM. For assistance with billing, claims, member eligibility, memos and other regulations, call the Virginia Medicaid Provider Helpline at the toll-free (800-552-8627) or in-state (804-786-6273) phone numbers. Forms to download and submit for drug authorizations through Sentara Health Plans. If this is a request for extension or modification of an existing authorization, provide the authorization number. For some services, a referral from your primary care provider (PCP) is needed. INTRODUCTION Service authorization, formerly known as prior authorization, is the process to approve specific services for an enrolled Medicaid, FAMIS Plus or FAMIS individual by a Medicaid enrolled provider prior to service delivery and reimbursement. Prior Authorization (PA) Form SHORT AND LONG-ACTING OPIOIDS Please note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc. Virginia is improving health care in rural communities through the Rural Health Transformation initiative. CoverMyMeds helps you complete prior authorizations quickly and accurately for any drug and any payer, including Medicare and Medicaid. The Health Plan doesn't require prior authorization for the first 20 visits for chiropractic services and the first 20 combined visits for physical therapy (PT) and occupational therapy (OT) per event and/or year for our Commercial (HMO, PPO, POS, EPO & WV PEIA), Medicare and WV Medicaid members. Forms We’ve designed the documents in this section to support you in your quality care of Magellan members. The Acentra Health (Service Authorization) contract excludes: Services managed under a It is the provider’s responsibility to check Member’s Medicaid eligibility prior to Service Authorization submittal. Include individual strengths/barriers/gaps in service, and written in own words of individual seeking treatment/or in a manner that is understood by individual seeking treatment. This site contains a wealth of resources for providers and the general public including Preferred Drug List information, P&T Committee information and Service Authorization forms. To design and deliver high-quality human services that help Virginians achieve safety, independence and overall well-being. Jul 1, 2025 · The MediCall System offers Medicaid providers 24/7 access to current member eligibility information, check status, claims status, prior authorization information, service limit information, pharmacy prescriber identification number cross reference, and information to access member eligibility and provider payment verification. This page offers quick access to the forms you use most. For this reason, Highmark removed West Virginia prior authorization forms from the Provider Resource Center (PRC). A library of the forms most frequently used by health care professionals. Reference site for the Preferred Drug List and Prior Authorization Programs, as well as for information on upcoming changes. Forms | HealthKeepers, Inc. Please use one form per member. This information is intended only for the use of the individual or entity named above. If you must mail or fax a PA request, use the form below that pertains to the service being requested. . Some services do not require Srv Auth and some may begin prior to requesting authorization. docx) from this site. Virginia Medicaid pharmacy precertification request form (opens in new window) Prescriber quick reference guide: This guide helps prescribers determine which Humana medication resource to contact for prior authorization, step therapy, quantity limits, medication exceptions, appeals and claims. Prior Authorization Request Form UniCare Health Plan of West Virginia, Inc. Prior authorization is required [for some out-of-network providers, outpatient care and planned hospital admissions]. ¤ Is Individual currently auxiliary grant eligible? Enter appropriate code (“0”, “1” or “2”) in the box. VIRGINIA MEDICAID REQUEST FOR DRUG SERVICE AUTHORIZATION COMMONWEALTH of VIRGINIA Department of Medical Assistance Services Requests for service authorization (SA) must include patient name, Medicaid ID#, and drug name. Refer to the Medicaid Durable Medical Equipment and Supplies Manual, Chapter IV, pages 4-7. The below forms must be sent as the top page with any attachments behind it. West Virginia has enrolled in the POST program, which allows patients to define their preferred end-of-life treatments. Dec 31, 2024 · Professionals completing this Request form should consider the following information: 1) Prior authorization must be obtained for coverage of MHS services as required by the member's benefit plan. Learn how to request prior authorization here. So bers under age twenty-one (21) and are administered through the DMAS Service Authorization Contractor. By assessing needs, sharing best practices, and advancing innovative solutions, the initiative expands access to high-quality, affordable care across the Commonwealth. Member must meet the minimum FDA-approved age. Prior Authorization (PA) Form for Stimulants/ADHD Medications for Children Less Than FDA Indicated Age and Adults Over 18 Virginia | HealthKeepers, Inc. doc/. The Sentara Health Plans Oncology Program is administered by OncoHealth For any oncology indications, the most efficient way to submit a prior authorization request is through the OncoHealth OneUM Provider Portal at https://oneum. Jun 14, 2024 · The Virginia do not resuscitate (DNR) order form is a statement that informs medical personnel that a patient does not want to receive CPR or other lifesaving treatments in the event of respiratory or cardiac arrest. Today’s date: completed prior authorization request form to 855-799-2553 or submit Electronic Prior Authorization CoverMyMeds® or SureScripts. Access Sentara Health Plans’ provider authorization resources, including drug and medical prior authorization forms, authorization lookup tools, policy updates, and behavioral health authorization guidance. Describe the most significant difficulties in these areas for this individual below and connect them to the symptoms described in criteria 1. Cardinal Care Medicaid Searchable Formulary FAMIS Formulary Pharmacy prior authorizations Some drugs or categories of drugs have a dedicated prior authorization form listed under the Pharmacy option on our Forms page. INTRODUCTION – SERVICE AUTHORIZATION IN FEE-FOR-SERVICE (FFS) AND MANAGED CARE ORGANIZATIONS (MCO) Plus or FAMIS individual by a Medicaid enrolled provider prior to service delivery and reimbursement. oncohealth. Find out more. Exceptions may be made if evidence of an atypical RSV season is identified in conjunction with the Virginia Department of All Out-of-Network services requested (EXCEPT where indicated in policy) shall require prior authorization by the Utilization Management Contractor (UMC) or the Bureau for Medical Services (BMS) before services are provided. If the form or document you are looking for is not found below, you can search our library of files. The intended recipient of this information should destroy the information after the purpose of its transmission has been accomplished or is responsible for protecting the Prior Authorization (PA) Form Dupixent® HealthKeepers, Inc. The approval time frame for Synagis® will begin October 1 and will be effective through March 31 of the following year. prior authorization: 800-901-0020 Fax: 800-964-3627 To prevent delay in processing your request, please fill out form in its entirety with all applicable information. Certain requests for prior authorization require additional information from the provider. Prior Approval Requests The recommended method for submitting a PA request is to key it directly into the secure Provider Portal. Members should be considered for buprenorphine analgesic treatment with either topical patch since this product has a ceiling effect with General Drug Prior Authorization Form West Virginia Medicaid Drug Prior Authorization Form http://www. Please provide the following information and fax this form to the number listed above. GLP-1 RECEPTOR AGONISTS FOR CARDIOVASCULAR RISK REDUCTION If the following information is not complete, correct, or legible, the SA process can be delayed. Consider non-pharmacologic and non-opioid pain treatments prior to treatment with opioids. Final eligibility for personal care services will be determined by DMAS, according to medical necessity, as documented in the member’s clinical documentation. Precertification request Please note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc. Here's what you need to know about referrals, preapprovals, and prior authorization requirements for Anthem Medicaid in Virginia. Some forms and downloads may also be available after logging into MES and the Provider portal. Jun 13, 2025 · Effective July 1, 2024, West Virginia Law (Senate Bill 267) mandates the electronic submission of prior authorization requests. (UniCare) precertification phone number: 1-866-655-7423 Fax: 1-855-402-6983 To prevent a delay in processing your request, please fill out the form in its entirety with all applicable information. The use of pharmaceutical samples will not be considered when evaluating the members' medical condition or prior prescription history for drugs that require prior authorization. Learn more about referrals and prior authorizations for West Virginia. Prior Authorization in Medicaid Prior authorization is the process by which health care payers require that medical providers receive approval before a specific item, service, or medication can be provided (Pestaina and Pollitz 2022). A POST form is similar to a DNR. Existing authorizations will be honored until renewal. us. Federal regulations allow Medicaid fee-for-service (FFS) programs and managed care organizations (MCOs) to use prior authorization to limit services in an effort REGISTRATION ON ATTREZO IS REQUIRED TO SUBMIT PRIOR AUTHORIZATION REQUESTS WHETHER BY FAX OR ELECTRONICALLY. Long-Acting Opioids (LAOs): LAOs are indicated for members with chronic, moderate to severe pain who require daily, around-the-clock opioid treatment and require a SA. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policy and procedures. Submit a new prior auth, get prescription requirements, or submit case updates for specialties. Feb 21, 2024 · Process for Submitting Service Authorizations for All Behavioral Health and ARTS Services All service Authorizations are now handled by Acentra Health (formerly KePro), who will oversee all service authorizations for behavioral health for fee for service members. Pharmacy Prior Authorization Form Please note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc. Aug 4, 2025 · The Bureau for Medical Services is committed to ensuring access to quality, innovative, and sustainable services that advance the health and well-being of West Virginians through the administration of Medicaid and CHIP. All prior authorization requests must now be submitted to Highmark via our provider portal (Availity ®). Out Prior Authorization Request Form – Confidential Please complete this form in its entirety. Confidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. Based on the CDC Guidelines for Prescribing O Nov 1, 2025 · Online tools and resources to help you manage your practice’s notification and prior authorization requests for Virginia Community Plan care providers. Information not provided or illegible writing may delay the review process. You can also learn about our pharmacy PA guidelines. Aug 1, 2025 · Effective July 1, 2024, providers are required to submit Commercial, PEIA, and Mountain Health Trust (WV Medicaid and CHIP) prior authorizations through The Health Plan (THP) provider portal. Sep 27, 2024 · Use the correct forms This is a friendly reminder that all providers are expected to submit Behavioral Health prior authorization requests to HealthKeepers, Inc. We would like to show you a description here but the site won’t allow us. Pages 1– in. Plans administered by Optum behavioral do not require prior authorization for routine outpatient services. Jun 30, 2025 · Prior Authorization forms for Sentara Health Plans Community Care and Sentara Community Complete (HMO-SNP) plans. Featured resources Pharmacy information Pharmacy information for providers including Preferred Drug Lists (PDLs), prior authorization information and other related resources can be found on the Pharmacy Information page . Difficulty with sensory integration. Our partner eviCore Pharmacy Prior Authorization Form Please note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc. Virginia Medicaid MHS ABA Program Important change to the Virginia Medicaid Applied Behavior Analysis (ABA) service authorization process: get the details Need help with the Provider Express secure portal? The Technical Support team is available by chat or by calling 1-866-209-9320. Refer to Molina Complete Care’s (MCC’s) provider website or prior authorization (PA) look-up tool/matrix for specific codes that require authorization. If individual has identified a history of trauma, please include trauma-informed care Service Authorization Overview The Department of Medical Assistance Services (DMAS) contracts with Acentra Health (formerly known as Kepro) to handle the Service Authorization process for Medicaid, Family Access to Medical Insurance Security (FAMIS) and FAMIS Plus clients in the fee-for-service programs. ytv sstx njozzew nlyxt xhjv tixo wkvml fxduqbk kliz dopqy hgmfrksc igidl lzfh nnebsiw vxo