Maryland Physicians Care Prior Authorization Form
Medstar family choice mfc 410 933 2200 or 800 905 1722.
Maryland physicians care prior authorization form. For more information about medications requiring prior authorization visit prior authorizations for medications. Request for rx prior authorization do not use for antipsychotic requests maryland medicaid pharmacy program fax. Opioid prior authorization form.
Maryland physicians care mpc 800 753 2851 877 328 9799. The nutritional supplement pre authorization form will need to be completed in addition to the current outpatient medicaid prior authorization form. Prior authorization criteria are established based on a collaborative effort using input from the current medical literature and based on evidence available at the time.
Maryland healthy kids provider forms. Newborn notification form pdf pharmacy prior authorization forms. This is a maryland medicaid pharmacy program requirement for all enteral and parenteral formula approval s.
Effective april 15 th maryland physicians care will require all durable medical equipment dme providers to complete and submit the nutritional supplement pre authorization form for any nutrition supplemental authorization requests. To see if a prior authorization is required for a service use our mpc pre authorization tool. Preauthorization forms for preauthorization please complete the appropriate forms for your request and fax it to 410 767 6034.
How do i verify enrollment of a patient. Maryland uniform consultation referral form pdf maryland uniform credentialing form pdf new prior authorization form pdf required form as of 4 1 21. Prior authorization for drugs below as well as drugs for hepatitis c should be sent to maryland physicians care at 866 207 7231 using pharmacy coverage determination request form pdf.
Medicaid help right in your inbox. Contact the state of maryland s eligibility verification system evs at 1 866 710 1447 or contact member services at 1 800 953 8854 to verify enrollment. Behavioral health services need to be verified by optum maryland.
Primary care physician change form pdf provider verification form pdf remote. Vision services need to be verified by superior vision. Managed care organizations listed and medicaid fee for service use this form for opioid prior authorization.
If you are uncertain that prior authorization is needed please submit a request for an accurate response. For specific details about authorization requirements please refer to our quick reference guide. Prior authorization for medications processed through maryland physicians care.
800 932 3918 please check the appropriate box for the prior authorization request. Print the applicable prior authorization form and fax to 1 800 953 8856 or contact the prior authorization department at 1 800 953 8854.