First Choice Medicaid Prior Authorization Form

Date:

What Do Cfc Services Include

Prior Approval for NC Medicaid Glasses on NC Tracks
  • Personal Assistance Services : Help with daily living activities and health-related tasks.
  • Habilitation: Services to help learn new skills and care for yourself.
  • Emergency Response Services : An alert system if you live alone or are alone for most of the day.
  • Support Management: Training on how to select, manage and dismiss attendants.

Who Can Get Cfc Services

You can get these services if you:

  • Are enrolled in STAR+PLUS or STAR Kids, and are not getting Long-Term Support Services through a 1915 waiver but may be on an interest list for one of those waivers and
  • Meet the eligibility requirements for entry into an Intermediate Care Facility for Individuals with an Intellectual Disability , Nursing Facility or Institution for Mental Disease .

Who Provides Cfc Services

Members are able to choose if their CFC services are delivered through Consumer Directed Services or Service Responsibility Option or through a provider agency. If you do not choose CDS, only certain providers can offer CFC services. These providers must be contracted with Superior to qualify and be approved to offer CFC services. Provider types include:

  • Licensed home and community support services agencies.
  • Certified HCS and TXHmL providers.
  • Licensed emergency response services agencies.
  • Qualified financial management services agencies if you choose CDS.

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How Does Cfc Help

CFC services are based on your needs and preferences. You can select and train a family member or someone else to provide these services. However, you cannot select a spouse. You also cannot select a legal guardian if you are under the age of 21.

CFC also helps you get services that help increase independence. These include learning how to use public transportation, help with social activities and learning about resources in your community.

For Reimbursement Requests At Less Than Cost Not Related To Brand Name Dispense As Written

Universal 17
  • For phone requests
  • For fax requests
  • Download and complete the Pharmacy Information Authorization form and send to 1-866-668-1214.
  • Note: For information on billing and rates, the Apple Health preferred drug list, and expedited authorization codes, please visit the Prescription Drug Program on our provider billing guide and rates page.

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    Applied Behavior Analysis Medical Necessity Guide

    The Applied Behavior Analysis Medical Necessity Guide helps determine appropriate levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. The ABA Medical Necessity Guide does not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any matters related to their coverage or condition with their treating provider.

    Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member’s benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.

    The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered for a particular member. The member’s benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.

    Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change.

    Nonparticipating Health Care Professionals/providers

    PCPs and plan participating specialists may refer members to a nonparticipating plan specialist if there is not a participating specialist in a particular field.

    However, plan health care professionals/providers who want to refer members to any nonparticipating health care professional/provider must contact Select Healths Medical Services department for prior authorization.

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    How Will Superior Members In A 1915 Waiver Get Their Cfc Services

    • DADS will help you get CFC services if you are in a waiver. These services will not cost you anything. If you get services through a waiver, you will continue to get the same services you get today. Superior will still provide doctor visits and hospital services if you are enrolled in one of these waivers:
    • Home and Community-based Services .
    • Texas Home Living .
    • Community Living Assistance and Support Services .
    • Deaf Blind with Multiple Disabilities .

    Icipating Specialty Care Health Care Professionals/providers

    Hotline: Insurance Network Fixes, Medicaid Overhaul, HIV Prior Authorizations

    Select Health encourages members to seek referral from their primary care provider for specialty care when such care is necessary. Prior authorization from Select Health is not required for participating plan specialists for office visits. Some services offered at the participating specialists office may require prior authorization.

    Participating specialists are advised to contact Medical Services prior to delivering a service if in doubt. For coordination and continuity of care, the specialty care physician is strongly urged to communicate all findings and any needs for follow-up care back to the PCP via a consultation record.

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    Prior Approvals And Authorizations

    Prior approval

    You will need approval before you get some medical procedures and for some medicines. Your primary care provider will ask for prior approval from First Choice. To find out if a procedure needs prior approval, please call Member Services at 1-888-276-2020.

    If you need prior approval, your doctor must complete a prior authorization form and return it to First Choice. If the request is not approved, you will get a letter telling you why. If you disagree with the reason, you can file an appeal. See prior authorization criteria .

    Some prescriptions must be approved before you can get them filled. If a medicine needs prior approval, your doctor must complete a prior authorization form. See our preferred drug list for more information about covered medicines.

    If the request is approved, a notice is sent to your doctor. You can then get your medicine.

    If the request is denied, you will get a letter explaining why. If you don’t agree with the denial, you can appeal the decision. To file an appeal, call Member Services at 1-888-276-2020.

    Ask your doctor if your drug needs prior approval when your doctor gives you the prescription. Most medicines do not require approval.

    For prior authorization and other pharmacy services questions, call Member Services at 1-888-276-2020. You can also call Member Services to suggest adding to or deleting a medicine in the First Choice Preferred Drug List.

    Physical Health Services That Require Prior Authorization

    Prior authorization is not a guarantee of payment for the service authorized. The plan reserves the right to adjust any payment made following a review of medical record and determination of medical necessity of services provided.

    Any additional questions regarding prior authorization requests may be addressed by calling 1-800-521-6622.

    Participants with Medicare coverage may go to Medicare Health Care Providers of choice for Medicare covered services, whether or not the Medicare Health Care Provider has complied with the Plan’s Prior Authorization requirements. The Plan’s policies and procedures must be followed for Non-Covered Medicare services.

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    What Is Community First Choice

    CFC is a Medicaid benefit that provides extra help for people with Intellectual and Developmental Disabilities or physical disabilities. CFC services can vary based on your goals and needs. Superior will work with the Department of Aging and Disability Services and Local Intellectual and Developmental Disabilities Authorities to help you get CFC services.

    What Is A Level Of Care Assessment Who Performs These Assessments

    Fillable Cdphp Prior Authorization/medical Exception ...

    An LOC assessment determines if you need care from a Nursing Facility, Intermediate Care Facility or Institution for Mental Disease. After an LOC assessment is done, Superior will work with you to complete a CFC assessment. Superior will partner with LIDDA to complete assessments for people 21 years old and over after the LOC has been approved. If you or anyone else thinks an assessment is needed, call Superior Service Coordination.

    Read Also: Does Medicaid Cover More Than Medicare

    How To Write

    Step 1 At the top of the page, enter the plan/medical group name, the plan/medical group phone number, and the plan/medical group fax number.

    Step 2 In the Patient Information section, enter the patients full name, phone number, address, DOB, gender, height, weight, allergies, and authorized representative information .

    Step 3 Under Insurance Information, provide the names and numbers of the patients primary and secondary insurance.

    Step 4 The third section demands the physicians name, specialty, address, contact person, NPI number, phone number, DEA number, fax number, and email address.

    Step 5 In the Medication section, provide the necessary information concerning the prescription drug being requested. Include the name, dose, frequency, length of therapy, quantity, administration, and administration location.

    Step 6 At the top of page two , enter the patients name and ID number.

    Step 7 Section of page two should be filled in if the patient has tried other medication for their condition. List the names of these medications, duration of therapy, and the response to this drug.

    Step 8 Section of page two is where the physician will list the diagnoses with the associated ICD codes.

    Step 9 Under Required Clinical Information, provide any lab results, comments, or additional information that will support the medical reasoning for prescribing this medication.

    Step 10 Prescriber must sign the bottom and include the current date.

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