... For members who are not hospitalized at the time of a routine prior authorization request, within 3 business days or up to 72 hours for expedited authorization requests. For both physician office and hospital outpatient visits, your health insurer may require you to get a referral or authorization. About Morton Hospital. MassHealth Application for PCA Services (PDF) PCA Evaluation Form (PDF) Prior Authorization Adjustment Form (PDF) For more details about the MassHealth PCA program, see the Commonwealth of Massachusetts PCA Regulations Manual from the MassHeath Provider Manual Series. Lab tests, x-rays and diagnostic imaging are covered. Open PDF file, 329.68 KB, for Bulletin 2017-04; Using Standard Prior Authorization Forms when Reviewing Requests for Hepatitis C Medication, Non-OB Ultrasound and SYNAGIS; Issued 9/11/2017 (PDF 329.68 KB) Contact the Financial Access Unit at 617-726-6828 if you have any insurance authorization questions or concerns. Kidney Disease Care. ... MassHealth Notification of Birth Form (NOB-1) Provider Audit Appeal Form Care Management Referral Form Dialysis, medicine and treatments are covered. In addition, our providers may be considered “In Network” or “Out of Network,” depending on the specifics of your health insurance plan, which could affect the amount you pay. Patient Financial Services With prior approval counseling and other treatments are covered. Depending on the member’s plan, providers must contact either NIA or Cigna. Pharmacy forms. You can also check and compare imaging costs by logging in to mybcbsri.com and clicking on “Find a Cost” Under “Tools & Resources” in the “Self-Service” menu. The Financial Access Unit also works directly with physicians’ offices and insurance companies to confirm that all required referrals and authorizations have been approved prior a patient’s visit. All three plans will require prior authorization for select services to ensure they are medically necessary. Please fax the completed request to eviCore, fax # (888) 693-3210. Referral and prior authorization. Cardiac Imaging Prior Authorization Form ... Non-Emergency Medically Necessary Ground Transportation Form PET — PET CT Prior Authorization Form Prior Authorization Request Form Psychological and Neuropsychological Assessment Supplemental Form. The following services require prior authorization through NIA’s High-Tech Imaging program. Personal support from an experienced professional. Check Prior Authorization Status As part of our continued effort to provide a high quality user experience while also ensuring the integrity of the information of those that we service is protected, we will be implementing changes to evicore.com in the near future. Download MassHealth Provider Forms. Cardiac Imaging Prior Authorization *All authorization requests for High Cost Radiology & Imaging are administered through eviCore healthcare. Morton Hospital is a 112-bed acute care community hospital serving patients and families in southeastern Massachusetts. Exams, testing and supplies are covered for asthma and other lung diseases. Asthma Care. Obesity Care. Care Management. Ordering providers must obtain authorization before requesting outpatient high-tech imaging services.
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