Manual do Provedor

PEDIDOS DE AUTORIZAÇÕES / RETRO-AUTORIZAÇÕES

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).

Se, por qualquer razão, 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 quarenta e cinco (45) dias corridos 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
PO Box 1840
Cranberry Twp., PA 16066-1840

O pedido de retroautorização garante apenas consideração 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 quarenta e cinco (45) dias corridos a partir da data do serviço não será levado em consideração.

Pagamento de retroautorizações

Se o provedor recebeu aprovação escrita 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 reivindicações, outlined in Section VI of Claims Payment. The claim must be received by Carelon within noventa (90) dias corridos a partir da data na carta de aprovação.

Abaixo está o link para o formulário de Retroautorização que deve ser preenchido e enviado ao Departamento Clínico.

Formulário de Autorização Retro - Somente Medicaid da Pensilvânia