Manual del proveedor

SOLICITUDES DE AUTORIZACIONES / RETRO AUTORIZACIONES

Upon receipt of a request for authorization for services, by phone, electronic, or fax transmittal, Carelon has ten (10) business days to enter a provider’s authorization. Providers should be able to access authorizations within 2 business days of a decision. An icon will appear on the ProviderConnect home page indicating that new authorization letters are available. Click on the link on the ProviderConnect home page to go to links to new authorization letters. Print the letters or save them to your computer. Only approval letters are electronic. Adverse determination letters and return of incomplete requests will continue to be sent to providers via US Mail. Providers may also request a fax-back copy of an authorization letter via touch tone telephone. Call 1-866-409-5958 and have available the provider NPI, fax number to receive the fax-back document, member ID number, authorization dates requested, and authorization number (if obtained previously).

Si por cualquier razón, the provider finds it necessary to request a retro-authorization for behavioral health service(s), the request must be received in writing no later than cuarenta y cinco (45) días calendario from the date of service. The request for behavioral health retro-authorization must be faxed to Carelon Health of Pennsylvania (Behavioral Health) Services (855-439-2444) to the attention of the Clinical Department or mailed to the attention of:

Carelon Health of Pennsylvania
Departamento Clínico
Apartado de correos 1840
Cranberry Twp., PA 16066-1840

La solicitud de retroautorización solo garantiza consideración of the request. The provider will receive written notification within thirty (30) calendar days from Carelon’s receipt of the request, approving or denying the service. Any requests for retro-authorization(s) received beyond cuarenta y cinco (45) días calendario a partir de la fecha de servicio no se tendrá en cuenta.

Pago de retroautorizaciones

Si el proveedor recibió aprobación por escrito for the retro-request for service(s) and has not previously submitted a claim, the provider should follow the procedures as outlined in the Carelon Provider Manual for submission of ajustes de reclamaciones, outlined in Section VI of Claims Payment. The claim must be received by Carelon within noventa (90) días calendario a partir de la fecha de la carta de aprobación.

A continuación se muestra el enlace al formulario de retroautorización que debe completarse y enviarse al Departamento Clínico.

Formulario de autorización retro: solo Medicaid de Pensilvania