Passport Health Plan (KY) - Kentucky Medicaid, A Managed Healthcare Organization, Medical Assistance, Medicaid, Medicare, Medicare Part D, Passport Advantage, Centers for Medicare & Medicaid Services (CMS), PDP, managed care health plan, Medical Assistance recipients, Health Insurance, Healthcare, Kentucky Childrens Health Insurance Program, KCHIP, AmeriHealth Mercy, extensive provider network, Physicians, specialists, pharmacies and hospitals Improving the Health and Quality of Life of our Members
 About Us  |  Providers  |  Members  |   Miembros  |  Pharmacy  |  News  |  Contact  |  Passport Advantage
Passport Health Plan Home > Passport Health Plan > Providers > Resources > "How To" Tutorials > Drug Prior Authorization Request
Providers
Login to Secured Services
Provider Communications
Bullet Provider Alerts
Bullet Provider Letters
Bullet Medical Office Notes
Bullet Provider Newsletters
Bullet Pharmacy News
Bullet Provider Services Year In Review
Services
Bullet Provider Recognition Program
Bullet Cultural & Linguistic Services Program
Bullet Provider Foreign Language Report
Bullet Pharmacy Services
Bullet Orientation, Workshops & Roundtables
Bullet iEXCHANGE®
Resources
Bullet Provider Manual
Bullet Provider Directories
Bullet Provider References
Bullet "How To" Tutorials - Authorizations & Referrals
Bullet HIPAA
Bullet Links to KCHS Department for Medicaid Services
Billing Information
Bullet EDI Questions and Answers
Medical Guidelines
Bullet Clinical Practice Guidelines
Bullet Health & Wellness: Important Member Information
Bullet QI Program Description
Bullet Summary of Annual Evaluation
Contact Information
Bullet How to Contact Passport Health Plan
Bullet Contact a Provider Representative
Website Evaluation Form
 
 

Helpful Hints Passport Health Plan Drug Prior Authorization Request

Purpose of Form

The purpose of the form is to request that the Plan approve a medication that is not on the Plan’s non-prior-authorization list.

Completing the Form

   
First Section

Prescriber and Member Information. Please include ALL requested prescriber and member information.

   
Second Section Requested Medication Information. Please check whether this is a NEW or RENEWAL request for this medication. Please include all requested information.
   
Third Section PCN/PLAN reply information. Do NOT write in this box.
   
Two of the most common reasons for denials are:
1. Incomplete Forms
2. Illegible Forms
   

Distributing the Form

Here is a quick reference guide for the appropriate distribution channels:
   
Fax

Pharmaceutical Care Network (PCN) at (800) 945-1815

   
Urgent Request Place a check next to URGENT REQUEST at the top of form. Explain reason for urgency under second section of the form (urgent fax line is reserved for requests that in the provider’s best professional judgment are potentially life threatening or pose a significant risk to the continuous care of the patient). Fax to urgent fax line (877) 636-9001.

Customer Help

If you need assistance with this form call:
  Customer Service Help Desk
(800) 777-0074

 
 
©2008 Passport Health Plan. Home | Partnership Login | Site Map | Email-to-Friend | Print | Search
Legal Statement & Terms of Use Visit AmeriHealth Mercy
National Committee for Quality Assurance - NCQA - Excellent Accreditation