Medication/Radiology Prior Authorizations

 

 

 

Rx Prescription Prior Authorization Most reasonable insurance companies provide a comparable and efficacious list of alternative medications; therefore, before launching on this tedious endeavor, review the companies’ formulary or preferred medication list first here or with the pharmacist who can suggest alternates.  

 

·         Managed Medicaid PA center  -links to formulary search/forms/phone #s for NY Medicaid. Buit by DOH and SUNY, it has a very useful and updated formulary section for all Medicaid managed insurances. 

 

·        “Straight” NY Medicaid Prior Authorization program

o   find Prior authorization forms for various meds

 

·        For Medicare Part D RX PA   -given the innumerable varieties of part D plans, it is much harder to find a matching formulary

Formularies/standard fax PA forms and other info can be searched by phone number or name of the plan.

 

 

Enteral Supplement Prior Auth – Medicaid Fee For Service ONLY

Medicaid Enteral Formula Prior Authorization Program 1-866-211-1736 automated, to speak to live person for questions 1-800-342-3005

A new law as of May 2011 now only provides Enteral Formulas to pts who are either tube fed or dx with a inborn metabolic diseases.  Ms. Juana Moya in VC 205 can help you to call and obtain telephone PA #. Please complete the work sheet NYS/DOH Prior Authorization Work Sheet, and give her a copy of your enteral feed prescription (with 5 refills/6 months), be sure to include the fax number of the pt’s pharmacy. Ms. Moya will obtain the PA number from Medicaid and fax the Rx for you to the pharmacy. A copy will be placed in your mailbox for your records. To complete the form above, you will need the patients Medicaid number, DOB, ht/wt, your attendings license number. Each can of formula usually carries an average of 250-300 calories. 

 

 

Imaging Prior Authorizations  -   (Imaging PAs will only be required for your cardiology/neuro testing – mainly nuclear stress testing and EMGs) Due to higher cost and frequent overuse of tests like MRI, CT, nuclear stress/stress echo, insurance companies use prior authorizations (PA) to justifying our testing.  A PA procedure requires providers make a phone call to insurance contracted care management companies, answering administrative and clinical questions. Depending on the company, this call can last anywhere from 10 minutes to over several calls over days/weeks. 

So some tips to help get it done:

1.     Know your CPT codes   Radiology   Cardiology codes, used to identify the test you are ordering (for EMG see referral page EMG section)

2.     Know your insurance company/contact info (for most updated info) – 

a.     Health First: uses Evacore Phone 1 866 242 5615Fax 1 800 540 2406 performs for all radiology PA for health first (for EMG call HF directly 888 394 4327) - has the most stringent and challenging procedures. To minimize losing telomeres waiting on phone use the fax process.  After a fax is submitted, it takes 24-72 hrs for the PA Submission to show up on the status tracking website, use this link below to receive confirmation # for approval (takes 2-4 work days). https://carriers.carecorenational.com/PreAuthorization/screens/AuthorizationLookup.aspx

Your fax needs to include :

                                                              i.      Patients insurance ID, DOB

                                                            ii.      Your attending’s Name and NPI, include your pager for call back in case they have questions.

                                                          iii.      Your visit note with clear description of indication for your test

                                                         iv.      CPT code of  test needed 

                                                           v.      Location of testing =Columbia Presbyterian Radiology 622 W. 168th St. NY NY 10032

b.     Health Plus Amerigroup:   call 1-800-714-0040 Monday through Friday 8:00 a.m.–5:00 p.m. They do not do fax, the process is <10 minutes w several clinical questions.  More info here

c.      VNS choice medicare  (cardiac testing, EMG) As of 12/14,   VNS CHOICE no longer approve any cardiac/EMG testing at Columbia, PFAs will be book pts for testing at Cornell.  VNS  1 866 791 2215/ VNS choice select health 1 866 783   

d.     NY Medicaid (straight medicaid)           Click here for form and fax # info           

e.     Affinity does not require PA for imaging tests in network (at NYP)

f.         National Benefit 1199-    10- 12 minute call, they ask for CPT code, NPI of attending, ICD code, location of testing (Columbia NYP Radiology), clinical justifications, and hospital tax ID#  (can’t post online ask the admin staff in VC205 or your PFA)