Gateway Health Plan Authorization Form

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Forms - providers.highmark.com

(9 days ago) WEBFind all the forms you need for prior authorization, behavioral health, durable medical equipment, and more. Medicare references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies

https://providers.highmark.com/training-and-resources/forms

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RADMD Highmark Wholecare (Gateway Health and Gateway …

(5 days ago) WEBWelcome to the Highmark Wholecare (Gateway Health and Gateway Health Medicare Assured) page. The documents below have been designed to help RadMD users navigate the prior authorization process for each program Evolent (formerly National Imaging Associates, Inc.) is responsible for. Additional process-specific training tools and …

https://www1.radmd.com/all-health-plans/highmark-wholecare-gateway-health-gateway-health-medicare-assured

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Prior Authorization Criteria Non-Formulary Medications

(7 days ago) WEBPRIOR AUTHORIZATION FORM Please complete and fax all requested information below including any progress notes, laboratory test results, or chart documentation as applicable to Gateway HealthSM Pharmacy Services. FAX: (888) 245-2049 If needed, you may call to speak to a Pharmacy Services Representative.

https://fm.formularynavigator.com/FormularyNavigator/DocumentManager/Download?clientDocumentId=qWDR5gCN5kyyJkc4QC1LlQ

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Pennsylvania Medicaid and Medicare Insurance

(Just Now) WEBPennsylvania Community Roots. Highmark Wholecare calls Pennsylvania home. We know that working in our communities helps us offer whole care to our neighbors. We proudly have: More than 400,000 members. A …

https://highmark.com/wholecare

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I. Requirements for Prior Authorization of Stimulants and

(7 days ago) WEBForm effective 01/05/2021. Gateway Health Plan Pharmacy Division Phone 800-392-1147 Fax 888-245-2049 . authorization for a Stimulants and Related Agent that was previously approved will take into account whether the beneficiary: 1. Has documentation of tolerability and a positive clinical response to the medication; AND. 2.

https://fm.formularynavigator.com/FormularyNavigator/DocumentManager/Download?clientDocumentId=Wm3NfJep0U2ANIFDGz2K5w

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Request for Drug Coverage - Highmark

(5 days ago) WEBHealth benefits or health benefit administration may be provided by or through Highmark Wholecare, coverage by Gateway Health Plan, an independent licensee of the lue ross lue Shield Association (“Highmark Wholecare”). Highmark Wholecare offers HMO plans with a Medicare ontract. Enrollment in these plans depends on contract renewal.

https://www.highmark.com/content/dam/digital-marketing/en/highmark/highmarkdotcom/wholecare/wholecare-working-images/documents/pdfs/medicare/formulary/request-for-drug-coverage-form.pdf

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Medications to Require Medical Prior Authorization

(4 days ago) WEBGateway Health Plan, an independent licensee of the Blue Cross Blue Shield Association (“Highmark Wholecare”). functionality will be added to the Authorization Request Forms to make completing and submitting your online requests easier and faster. • The prior authorization look up tool (accessed via NaviNet) will be updated to show

https://content.highmarkprc.com/Files/Wholecare/Updates/J_CodePriorAuthFeb22Care.pdf

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Provider Resource Center

(8 days ago) WEBMA30 - Hysterectomy Spanish. MA31 - Sterilization Form - English. MA300X - Medical Assistance Provider Order Forms for Providers. Maternity Outcome Authorization Form. Member Benefit Packages / Co-Pay Matrix. Member Outreach Form. Obstetrical Billing Guide. OB Care Enhancements Provider Training. Obstetrical Needs …

https://wholecare.highmarkprc.com/Medicaid-Resources/Forms-Reference-Materials

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Medications to Require Medical Prior Authorization - Valley …

(9 days ago) WEBGateway Health Plan, an independent licensee of the Blue Cross Blue Shield Association (“Highmark Wholecare”). functionality will be added to the Authorization Request Forms to make completing and submitting your online requests easier and faster. • The prior authorization look up tool (accessed via NaviNet) will be …

https://www.valleypreferred.com/wp-content/uploads/02072022-Gateway-HMRK-Wholecare-MEDICARE-ASSURED-Medication-Prior-Auth-EFF-2.21.2022.pdf

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Medicaid Insurance Program Pennsylvania Highmark …

(3 days ago) WEBThis information is issued on behalf of Highmark Wholecare, which is an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare serves a Medicaid plan to Blue Shield members in 13 …

https://www.highmark.com/wholecare/medicaid

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Prior Authorization Code Lookup - Highmark Health Options

(Just Now) WEBReview the Prior Authorizations section of the Provider Manual. Call Provider Services at 1-844-325-6251, Monday–Friday, 8 a.m.–5 p.m. Or contact your Provider Account Liaison.

https://www.highmarkhealthoptions.com/providers/prior-auth-lookup.html

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Provider Resource Center

(5 days ago) WEBProvider Resource Center. In December 2016, the 21st Century Cures Act was enacted into law by the 114th United States Congress. Section 212006 of the Cures Act requires all states to implement the use of Electronic Visit Verification (EVV) for Medicaid-funded personal care and home health services that require an in-home and …

https://wholecare.highmarkprc.com/Provider-Resources/Netsmart-Electronic-Visit-Verification-EVV

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Gateway Health Plan Pharmacy Division - MMITNetwork

(7 days ago) WEBForm effective 1/1/20 Gateway Health Plan Pharmacy Division Phone 800-392-1147 Fax 888-245-2049 OR iv. Failure to achieve glycemic control as evidenced by the beneficiary’s HbA1c values using a GLP-1 receptor agonist AND c. Will not be using the requested agent in combination with any other product containing a GLP-1 receptor agonist; AND d.

https://fm.formularynavigator.com/FormularyNavigator/DocumentManager/Download?clientDocumentId=y4OpuRnDmE2oUVSqn13tHg

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BENLYSTA-Gateway-Enrollment-Form-English.pdf

(Just Now) WEBReturn to Page 2 and obtain the patient’s signature. Please note: HIPAA Signature is required. BENLYSTA Cares signature is optional. Next Steps. Provide a signed copy of this form to the patient. Fax completed enrollment form to 1-877-850-9901 or submit electronically to Benlysta Gateway at www.BenlystaGatewayOnline.com.

https://www.benlystahcp.com/content/dam/cf-pharma/hcp-benlystahcp/en_US/pdf/BENLYSTA-Gateway-Enrollment-Form-English.pdf

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Medicare Grievances and Appeals Highmark Wholecare

(8 days ago) WEBRequest for Medicare Prescription Drug Coverage Determination Instructions. To file a request, you can: Send us a request by fax to: Medicare: 1-888-447-4369. Mail a request to: Highmark Wholecare. Attn: Pharmacy Department. P.O. Box 22158. Pittsburgh, PA 15222.

https://www.highmark.com/wholecare/legislative-resources/medicare-grievances-and-appeals

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Horizon NJ Health QUICK REFERENCE GUIDE

(7 days ago) WEBFor questions about Behavioral Health claim submissions, please call 1-800-682-9091. PRIOR AUTHORIZATION To confirm Horizon NJ Health’s receipt of a Prior Authorization request, precertification must be obtained prior to an elective or non-urgent admission or before services that require precertification are rendered.

https://www.horizonnjhealth.com/sites/default/files/Quick_Reference_Guide.pdf

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Traditional Plan Claim Form - Horizon BCBSNJ

(5 days ago) WEBTHE FOLLOWING AUTHORIZATION TO RELEASE INFORMATION MUST BE COMPLETED: NEW JERSEY STATE HEALTH BENEFITS PROGRAM Traditional Plan Claim Form 14. I the undersigned, authorize and request Horizon Blue Cross Blue Shield of New Jersey, to make payment for benefits which may be due herein to: 0704 …

https://www.horizonblue.com/sites/default/files/2016-09/Horizon-BCBSNJ-0704-Claim-Form-Medical-Traditional-SHBP.pdf

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Horizon Blue Cross Blue Shield of New Jersey Points of Contact

(3 days ago) WEBHorizon Behavioral HealthSM Provider Relations, credentialing and contracting questions Authorizations, complaints, appeals and/or general inquiries eBusiness helpdesk 1-800-397-1630 1-800-626-2212; 1-800-991-5579 (for NJ State Health Benefits Program/School Employees Health Benefit Program) 1-888-247-9311

https://www.horizonblue.com/sites/default/files/2017-04/2017_Navigating_Horizon_POC_Worksheet_FINAL.pdf

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I. Requirements for Prior Authorization of Antidepressants, …

(7 days ago) WEBForm effective 01/05/2021 . Gateway Health Plan Pharmacy Division Phone 800-392-1147 Fax 888-245-2049 . I. Requirements for Prior Authorization of Antidepressants, Other . A. Prescriptions That Require Prior Authorization . Prescriptions for non-preferred Antidepressants, Other. See the Preferred Drug List (PDL) for

https://fm.formularynavigator.com/FormularyNavigator/DocumentManager/Download?clientDocumentId=rWuNlWdTjkmxjnpQVZdf2w

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Prior Authorizations :: The Health Plan

(6 days ago) WEBMedical Prior Authorization Request Form. Molecular Pathology Request Form. Electronic Claim Fax Cover Sheet. Prior Authorization for SUD Form. Prior Authorization for Drug Screening Form. Pharmacy Pre-Authorization and Notification Form. Authorization to Disclose Health Information to Primary Care Providers.

https://www.healthplan.org/providers/prior-authorization-referrals/forms-prior-auth-list-notices

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Quick Reference Guide for Horizon Behavioral Health Providers

(7 days ago) WEBPlan (FIDE-SNP), Managed Long Term Services and Supports (MLTSS), Horizon NJ Health and Medicare Advantage Members will not need a referral from their PCP to see a behavioral health provider. Authorization is required for many behavioral health services. To obtain an authorization, please call the Provider Services number card.

https://s21151.pcdn.co/wp-content/uploads/HorizonNJHealth-QuickReferenceGuide-NewBenefits10.1.pdf

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Requirements for Prior Authorization of Antipsychotics

(7 days ago) WEBGateway Health Plan Pharmacy Division Phone 800-392-1147 Fax 888-245-2049 . I. Requirements for Prior Authorization of Antipsychotics A. Prescriptions That Require Prior Authorization Prescriptions for Antipsychotics that meet any of the following conditions must be prior authorized: 1. A non-preferred Antipsychotic.

https://fm.formularynavigator.com/FormularyNavigator/DocumentManager/Download?clientDocumentId=eChOKVmAfEuYzaa3ICYc9w

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