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Hamaspik Medicare

Summary of Services Requiring Prior Authorization

(consult Provider Manual for full list)

 

General Rules

• Urgent and Emergency Care DO NOT require Prior Authorization.
• Excluded services are not covered. Excluded services will be denied as a non–covered benefit, per the Member’s Evidence of Coverage (EOC).
• Providers are responsible for verifying eligibility and benefits before providing services to all members. Prior Authorization is not a guarantee of payment for services.
• Payment is made in accordance with a determination of the member’s eligibility, benefit limitations/exclusions, evidence of medical necessity during the claim review and provider status.
• Failure to obtain Prior Authorization prior to giving care for the services listed below may result in a denial for reimbursement.
• Services not requiring Prior Authorization will be subject to audit. If in an audit those services did not meet medical necessity, there will be a possibility of recoupment.
• If clinical documentation supporting claims are not provided, Hamaspik may deny for not having the information required to determine medical necessity.
• If a member is admitted to your facility, you must notify Hamaspik within 24 hours.
• Non-Participating (Out of Network Providers) require out-of-network authorization (OON approval) prior to providing any services, except for Urgent and Emergency Services.
• Except in an emergency, any service that is being performed in a hospital setting requires a prior authorization.
• Please refer to the Hamaspik Medicare provider manual on our website https://www.hamaspik.com/providers; General Requirements for Claims Submissions.

 

Please send completed Prior Auth Request Form, prescription from referring provider, and supporting clinical documentation pertaining to this request to: MedicareRequests@hamaspikchoice.org; Fax: 845-503-1911

If you have questions or updates regarding your request, please contact us at 1-888-426-2774 x608.

Prior Auth Request Form

The following time frame standards apply to all services requiring prior authorization:

 

• Elective Services - 14 days prior to the scheduled elective service. If contact cannot be made 14 days prior to the scheduled service, it should be made as soon as medically possible prior to the scheduled service.
• Urgent and Emergency Services –Prior to urgent services being rendered. If contact cannot be made prior to an urgent service, then contact must occur within one business day of the service.

 

Services Requiring Prior Authorization - Utilization Review Information

Acupuncture and Chiropractic Services

• American Specialty Health
• Fax: 1-877-427-4777; Phone: (800)-848-3555 or (800)972-4226
• https://www.ashlink.com/ASH/site/authentication/login.aspx?ReturnUrl=%2fASH

All Inpatient Admissions (including inpatient, long-term acute hospital, Mental Health, Acute Rehab, Sub-acute/Short-Term Rehabilitation, Skilled Nursing Facility) and Hospital Observation Stays

• Behavioral: Carelon Healthcare Services 866-201-1401 Medical: Hamaspik Utilization Mgmt.
• Email: MedicareRequests@hamaspikchoice.org;
• Fax: (845)503-1911; Phone: (888) 426-2774 x 608

Dental Services (Submit to DentaQuest)

• DENTAQUEST:
• Fax: (262)241-7150; Phone: (855) 343-4267
• Email: benefits@dentaquest.com

Vision Services (Optometry - Submit to EyeQuest)

• EYEQUEST:
• Fax: (888)696-9552; Phone: (888) 824-2014
• Email: eyequest@dentaquest.com

Durable Medical Equipment (DME) and Prosthetics including all DME rental

• Hamaspik DME Dept.
• Fax: (845)503-1511; Phone: (888)426-2774 x612
• Email: dme@hamaspikchoice.org

All non-emergent transport including Ambulance and Air Ambulance

• Hamaspik Transportation Dept.
• Fax: (845) 503-1998; Phone: (888) 426-2774 x615
• Email: transportation@hamaspikchoice.org

Specialty Prescriptions may require Prior Auth, Step-therapy, or have quantity limits as per Formulary

• MagellanRX (complete PA form on hamaspik.com)
• FAX: 1-800-424-3260;
• Phone: (800)424-4437 -Coverage Determinations;
• Helpdesk (800)933-3175

Skilled Services (PT, OT, ST, MSW)

• Hamaspik Auth Dept
• FAX: (845)503-0911
• Phone: (888)-426-2774 #608
• Email authorizations@hamaspikchoice.org
• Skilled Service Form for Medicaid CHHA services
• Prior Auth Request Form for Medicare services

 

All Experimental/Investigational Services

All Out-of-Network Services (OON) and referrals

All Surgeries/Procedures/Testing when performed in an Inpatient, Outpatient

facilities, and select office procedures: Advanced Radiology (including nuclear

medicine), MOHS Surgeries, Endoscopies/Colonoscopies (other than screening

colonoscopies), Bunionectomies, Laser Surgery

Any scheduled service that is being performed in a hospital setting

Cardiac Rehabilitation, Pulmonary Rehabilitation and Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services

Diagnostic Tests Procedures -- Authorization is required for certain diagnostic procedures, non-lab tests and genetic testing procedures, MRA, MRI, PET Scans. Routine lab tests do not require prior authorization.

Enteral and Total Parenteral Nutrition

Home Health Therapies /CHHA Services: Physical, Occupational, Speech Therapies, Social Work, Registered Nurse, Home Health Aide Services

Hyperbaric Oxygen Therapy

MAP Plan Only Long-term Care Services including: Registered Nurse/ Private Duty Nursing/PDN, Adult Day Care*, Social Day Care*, Personal Care Assistance Services*, Consumer Directed Personal Assistance Services*

Medical Nutritional Therapy

Nuclear Medicine

Organ Transplants/ Evaluations

Outpatient Therapies

Pain Management

Radiation Therapy

Radiology

Sleep Studies

• Hamaspik Utilization Mgmt.
• Email: MedicareRequests@hamaspikchoice.org;
• Fax: (845)503-1911; Phone: (888) 426-2774 x 608

 

*Authorization Request Form must be submitted with prescription from referring Provider for all services requiring Prior Authorization

Some Services Require additional forms to be completed (i.e., Social/Adult Day Care, PCA, CDPAS). Please visit www.hamaspik.com for required forms.

Visits to in-network Primary Care Physicians and Specialists (including ophthalmologists do not require Prior Authorizations)

Prior Authorization Request form

 

Hamaspik Claims Department

 

 

• Claims must be completed accurately and in full, in accordance with the instructions presented in Hamaspik’s provider manual. (See subsequent paragraphs). Hamaspik cannot pay claims that are inaccurate or incomplete.
• Claims must be submitted on a CMS-1500 form or electronic equivalent (professional claims) or UB-04 or electronic equivalent (institutional claims).
• Procedures must be identified by Current Procedural Terminology (CPT-4) or HCPCS codes. Diagnoses must be identified by ICD-10-CM diagnosis codes.
• Place of service (POS) must be identified using the codes established by CMS. These codes apply to paper submittals of professional claims. Valid place of service codes for electronic submittals are included in providers’ implementation guides for HIPAA-compliant electronic transactions.
• Procedures and diagnoses should be coded to the highest degree of specificity. For example, include 7th digit on ICD-10-CM codes when applicable.
• Claims with referral or prior authorization requirements must include the authorization number.
• Facility billers must include a revenue code to identify services rendered.
• All required supporting material must be made available to Hamaspik upon request.
• Claims submitted to all payors, must include an NPI to identify each provider for which data is reported on the claim. Hamaspik cannot accept any claims that do not include an NPI.
• Taxonomy codes are required on all claim submissions. Claims submitted without taxonomy will be returned. Providers may have multiple taxonomy codes and should only include the taxonomy code that applies to the services performed and reported on the claim submission.
• All claims must be submitted to Hamaspik Inc. within the timeframe specified in the provider agreement. Out of network providers must submit claims within 120 days from date of service.