Manuel du fournisseur

DEMANDES D'AUTORISATIONS / RETRO-AUTORISATIONS

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, pour n'importe quelle raison, 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 quarante-cinq (45) jours civils 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 Santé de Pennsylvanie
Département clinique
Boîte postale 1840
Cranberry Twp., PA 16066-1840

La demande de rétro-autorisation ne garantit que considération 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 quarante-cinq (45) jours civils à compter de la date du service ne seront pas pris en considération.

Paiement des rétro-autorisations

Si le fournisseur a reçu approbation écrite 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 règlement des sinistres, outlined in Section VI of Claims Payment. The claim must be received by Carelon within quatre-vingt-dix (90) jours civils à partir de la date de la lettre d'approbation.

Vous trouverez ci-dessous le lien vers le formulaire de rétro-autorisation qui doit être rempli et envoyé au service clinique.

Formulaire d'autorisation rétro - Pennsylvanie Medicaid uniquement