Please note that inclusion of items or services in this list does not indicate benefit coverage. West Virginia (WV) You may also contact Optum directly at the following numbers: Prior Authorization Form (Optum Rx) for IHS and 638 Tribal Facilities/Pharmacies. Please ensure you have the latest version of Adobe Reader on your system. Confidential Exchange of Information Form, Uniform Treatment Plans (UTP) Bone Marrow Heart Intestine Kidney Lung Pancreas Surgical Procedures Health Services Approval Process. District of Colombia (DC) All outpatient and EAP claims should be submitted electronically via Provider Express or EDI. Optum ® has the nation’s largest performance-tiered network with more than 185,000 active network providers. Admissions for Alcohol, Drug, and/or Substance Abuse or Mental Illness: Call Behavioral Health at: 800-579-5222. Ohio (OH) If the patient is not able to meet the above standard prior authorization requirements, please call 1-800-711-4555. Always come to this page to assure you are utilizing the most current request form. Michigan (MI) Prior Authorization What does it mean to get prior authorization? These services must be authorized. Maryland (MD) You can reach our Prior Authorization team at: 877-370-2845, TTY 711 for hearing impaired 8 a.m. – 5 p.m., Mon – Fri Language translation assistance is available upon request United Health Card Provider Phone Number: (877) 842-3210. Maryland Department of Health (MDH)/Behavioral Health Administration (BHA) pay for behavioral health services. The forms and education on this page align with that approach. Independent of Prior Authorization, notification by the facility is required for inpatient admissions on the next business day following an admission for Urgent/Emergent, Scheduled/Elective, Medical/Surgical, Out of Area, Hospice, Skilled Nursing Facility and Ob services. Oregon (OR) Behavioral Health Authorization Forms. If requesting TX SB 58 Services, fax completed TX UTP to 1-877-450-6011, Wellness Assessment Forms * does not apply to Unison membership. On 2/15/2020, Optum Alaska began processing 1115 Waiver SUD Service Authorizations requests, for services on and after 2/15/2020. 2 Optum Medical Network assesses new technology on an ongoing basis. Bone Marrow Heart Intestine Kidney Lung Pancreas Surgical Procedures 2. Transcranial Magnetic Stimulation (TMS) Authorizations Forms, Washington (state) IMC Critical Incident Report Form, Disclosure Provider Form – Roster Template (Excel file), Disclosure Provider Form – Roster Addendum, MN Care Advocate’s Fax # is 1/855-454-8155, MN Autism and EIDBI Forms and Information, Mental Health Intensive Outpatient Program Forms, Assertive Community Treatment (ACT) Form (for non-contracted providers only), DBT Request Form (for non-contracted providers only), Intensive Community Based Services (ICBS) Form, Intensive Community Based Services (ICBS) Monthly Update Form, Medica Behavioral Health Services and Authorization Requirements, Mental Health Retrospective Request Form - Medica Behavioral Health - MN CAC, Transcranial Magnetic Stimulation (TMS) Initial Request Form, Note: Adobe Acrobat Reader is required to view and print PDFs, Clinician Tax ID - Add / Update Online Form, Clinician Expertise/Specialty Attestation, Electronic Payments & Statements (EPS) here, http://bookstore.gpo.gov/catalog/government-forms-phone-directories, Optum Idaho Optum Supports & Services Manager (OSSM), Blank Person-Centered Service Plan Form in English, Blank Person-Centered Service Plan Form in Spanish, APA DSM5 Level 2 Substance Use Parent of Child Age 6 to 17, Telephonic Support Services - Provider Handout, MBH Telephonic Support Services - Referral Information for Providers, Telephonic Support Services - What Members Can Expect, Medication Assisted Treatment (non-methadone) Request Cover Sheet, Methadone Maintenance Assessment Cover Sheet, Substance Abuse Retrospective Request Form, Substance Abuse Service Request Cover Sheet. Idaho (ID), Illinois (IL) Prior Authorization is requested and provided for the treatment or services utilizing the new technology. Texas (TX) Any treatment or services that involve new technology will not be covered and paid unless: Optum Medical Network has found the new technology meets requirements for coverage under the member’s plan of coverage, and Prior Authorization is requested and provided for the treatment or services utilizing the new technology. Find answers to your questions regarding a claim audit on medical records. United Behavioral Health (UBH) was officially formed on February 2, 1997, via the merger of U.S. Behavioral Health, Inc. (USBH) and United Behavioral Systems, Inc. (UBS). Get support, answers and expert care. Pharmacies can access patient info and claim details and get forms. Maryland’s Public Behavioral Health System has defined these services. Apply to Prior Authorization Specialist, Medication Manager, Senior Customer Service Representative and more! REMINDER: for Behavioral Health services follow the pre-authorization process for Prestige when requesting services on or after 1/1/2021. Discover the benefits of patient-centered care, Useful wellNess articles and access to the patient portal, Visit the medical professionals site to learn more, Click here for applicable CPT/HCPCS Codes, Click here for new CPT/HCPCS codes requiring prior authorization. Other ways to submit a prior authorization If you are experiencing technical difficulties, please call us at 1-800-711-4555 to submit a verbal PA request. Purchase items with billed charges of $750 or greater per line item require prior authorization; this includes non-custom orthotics. US Virgin Islands (VI) ACN Group IPA of New York, Inc. Prior authorization is required for all rentals and custom equipment, including items related to or part of the rental or custom equipment. For urgent or expedited requests please call 1-800-711-4555. 4 All foot orthotics regardless of billed charge, other orthotic device greater than $1000 billed charge per device. Please complete and submit the request before providing the service to a member. Alaska (AK) Medical Documentation. For faster claims reminbursement with less hassle, it is strongly encouraged that you sign up for electronic funds transfer (EFT) via our Electronic Payments & Statements (EPS) here. 1 Admissions for Alcohol, Drug, and/or Substance Abuse or Mental Illness: Call Behavioral Health at: 800-579-5222. VA supports evidenced-based behavioral care. United Behavioral Health operating under the brand Optum BH1173_11.14.17 PROVIDER ALERT Changes to Prior Authorization Requirements November 29, 2017 Dear Provider: We are pleased to inform you that effective January 1, 2018, we are removing prior authorization requirements for the services listed below. If you are unable to use electronic prior authorization, you can call us at 1 (800) 882-4462 to submit a prior authorization request. Prescribers can access prior authorization systems and complete compliance requirements. To support an evidence-based approach, medical documentation must be submitted for VA review. Virginia (VA) Service Authorizations for dates of service on or after 2/15/2020 should be submitted to Optum. UMR, and the plan also uses: (a) United Behavioral Health (“Optum”) as their behavioral health vendor, (b) Optum Rx as their pharmacy administrator, and (c) UnitedHealthcare’s Choice Plus provider network. North Dakota (ND) Behavioral Health: Optum Behavioral Health Phone: (800) 579-5222 continued on back Other ways to submit a prior authorization If you are experiencing technical difficulties, please call us at 1-800-711-4555 to submit a verbal PA request. There is only one Wellness Assessment form; it is the same one that is offered to members at the first and second time. Prior Authorization Forms and Policies Pre-authorization fax numbers are specific to the type of authorization request. We are happy to answer any questions you may have. Nebraska (NE) Prior Authorization is not required for emergency or urgently needed services. Providers can contact ColoradoPAR at 888-801-9355. Using health care intelligence identifies the best behavioral health interventions Research has shown that integrating behavioral and medical health care improves outcomes and patient experience. You now have several options for submitting your Prior Authorization requests to OptumCare: • If you have your own secure system, please submit authorization requests to: LCD_UM@optum.com • If you do not have a secure email in place, please contact our service center at 1-877-370-2845. Payment for authorized services is contingent upon verification of eligibility for benefits, the benefits available in the member’s plan, the applicable contractual limitations, restrictions and exclusions. Request prior authorization for Personal Care Attendant (PCA) Services What you need to know MassHealth Guidelines for Medical Necessity Determination Prior Authorization for Non-Pharmaceutical Services - Frequently Asked Questions Medical Necessity Review Forms MassHealth Drug List Prior Authorization Forms for Pharmacy Services Inpatient claims may be submitted through Electronic Data Interchange (EDI) through the clearinghouse of your choice. Vermont (VT) Behavioral health — assessment services and intensive outpatient treatment All PARs processed by the ColoradoPAR program are submitted through the Colorado PAR web portal. Any treatment or services that involve new technology will not be covered and paid unless: Optum Medical Network has found the new technology meets Find help for mental health, ... Website: Optum Customer Portal OptumRx – Health Care Professionals Portal. • All Prior Authorization information on this document relates to Providers who belong in the AllWays Health Partners Network only (In-Network Providers). List eachsubstance, the amount used, the frequency, the date of last use, the length of use, and longest 1. ... this authorization at any time by notifying Optum in writing; however, the revocation will not have an effect on any actions taken prior to the date my revocation is received and processed. Connecticut (CT) You should verify benefits prior to requesting authorization. Florida (FL) Prior authorization requests for behavioral health services are submitted to RMHP ; Prior authorization requests for physical health services are submitted to ColoradoPAR following Health First Colorado rules. Click here to download a printable list of 2015 Prior Authorizations. 1 Admissions for Alcohol, Drug, and/or Substance Abuse or Mental Illness: Call Behavioral Health at: 800-579-5222.. 2 Optum Medical Network assesses new technology on an ongoing basis. Wellness Assessments are available here, on the Forms page, at the secured user section, or by mail. Ordering care providers will complete the notification/prior authorization process online or over the phone. Prior Authorization Request Form - OptumRx. Health Details: Yes, all outpatient physical, occupational, and speech therapy performed in a hospital must be authorized after the initial evaluation visit.To obtain Optum/OrthoNet authorization, providers should submit a Patient Summary Form (PSF750) within 3 days of the initial visit via www.myoptumhealthphysicalhealth.com. You can reach our Prior Authorization team at: 877-370-2845, TTY 711 for hearing impaired 8 a.m. – 5 p.m., Mon – Fri Language translation assistance is available upon request Colorado (CO) The following forms are for services requiring prior authorization. Largest behavioral health network in the U.S. Easy access to high-quality mental health and substance use disorder services is essential to the health and well-being of the people we serve. OptumHealth Physical Health is comprised of: OptumHealth Care Solutions, LLC. Transplants For transplant services, call OptumHealthdirectly at 888-936-7246 or call the notification number on the back of the health care ID card. We will ask for your email address and will The complete list of services that require prior authorization for imaging services can be found on the Medicare Advantage policies … Here you can print out Wellness Assessments that can be pre-populated with the name of the clinician* and member name. We have been operating under the brand Optum since 2012. Optum Medical Network assesses new technology on an ongoing basis. To request authorizations for services that occurred before 2/15/2020, please contact the Division of Behavioral Health. Hours OptumCare ® Network of Arizona … South Dakota (SD) United Health Care, Optum, and United Behavioral Health Phone Numbers. Missouri (MO), Montana (MT) It is advised to download each Wellness Assessment rather than copy because photocopying will deteriorate the face quality of the form which could lead to technical difficulties in the ability of Optum to read the forms when you fax them to us. United Behavioral Health operating under the brand Optum BH1173_11.14.17 PROVIDER ALERT Changes to Prior Authorization Requirements November 29, 2017 Dear Provider: We are pleased to inform you that effective January 1, 2018, we are removing prior authorization requirements for the services listed below. See lower right of this page for a link to additional information. (Will complete an out-of-network superbill if required) Other: Requests for form completion: $10-$100.00 Iowa (IA) Arizona (AZ) However, should the therapy treatments continue past 2/1/2020 then authorization of those visits on or after 2/1/2020 will be required. Admissions for alcohol, drug, and/or substance abuse or mental illness: Call OptumCare® Behavioral Health at: 800-579-5222. Website: Optum Customer Portal OptumRx – Health Care Professionals Portal. Many insurance plans also require patients or family to request and obtain prior authorization for mental health services/treatment. Optum administers a wide range of benefits. New Jersey (NJ) The process for requesting authorization for select services is below. Pennsylvania (PA), Puerto Rico (PR) Members and providers may also access Optum’s Live and Work Well website for more information on behavioral health benefits. Tennessee (TN) Arkansas (AR) For paper claim submission, facilities should use the industry standard UB-04 claim form using contracted revenue codes. Behavioral Health. • Prior the implementation SB74, Providers were required to conduct a behavioral health screening using the Client Status Review (CSR) prior to every treatment plan review. 1 Admissions for Alcohol, Drug, and/or Substance Abuse or Mental Illness: Call Behavioral Health at: 800-579-5222.. 2 Optum Medical Network assesses new technology on an ongoing basis. Medical specialty drugs: NovoLogix. OPTUM Health Behavioral Solutions - Provider Express Optum/Life Strategies Behavioral Health Release of Information Preferred Medications List Medical Documentation. Provider Relations. Prior Authorization Utilization Review Statistics The following information is provided to comply with a regulatory requirement for states requiring disclosure of information for … We’ve created this reference guide of resources to help primary care providers screen patients for depression, Attention Deficit Hyperactivity Disorder (ADHD) and alcohol/substance misuse. 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