Resources

    Prior Authorization- Information for Physician Practices

    MSNJ's  2017 House of Delegates Resolution Substitution 4A: Prior Authorization asked that MSNJ study the problems of prior authorization; compile prior authorization measures online; and work with the New Jersey Department of Banking and Insurance (NJ DOBI) and payers to streamline the process. Click on the image below to read our Study. 

     

    Prior authorization hurts patients and physicians. It’s time to #FixPriorAuth.

    New Jersey Department of Banking & Insurance Independent Health Care Appeals Program (IHCAP)

    DOBI's Independent Health Care Appeals Program established a three-stage appeal process to address payer denials of

    prior authorization/utilization management requests.

     NOTICE

     

    Physicians are required to post notice of this program in their offices. 

     

    DOBI IHCAP RESOURCES:


     

     

     

     

     

     

    Call  DOBI at 1-888-393-1062, extension 50998 or (609) 777-9470, ext. 50998 for help with IHCAP.


    Electronic Prior Authorization (ePA) Information

    The 2016 CAQH Index indicates that the healthcare industry could save up to $412 million, nationally, by moving to ePA.

     

    Learn how to implement ePA in your practice:

    Watch videos from the AMA on:

    The Prior Authorization Burden;
    Simplifying Prior Authorization with ePA; and
    The Better Way: ePA and Beyond.

     

    Learn how to work with Aetna electronically through their:

    Educational webinars;
    List of electronic transaction vendors;
    Electronic savings calculator; and
    Electronic transaction tools.

     

     

     

    Learn how to utilize UHC's ePA tools:

    PreCheck MyScript- integrated prescription ePA solution
    Prior Authorization & Notification App through Link- resources and training


    Payer Policies

    Below are links to payer prior authorization policies available online. This is not a comprehensive list, as many policies were only available to physicians through payer portals and payer policies change frequently. These links will be updated periodically; however, we cannot guarantee the accuracy or timeliness of the information provided. Before providing a service to a patient, it is recommended that you directly access the payer portal and contact the plan to determine whether prior authorization is required. 

    TABLE OF CONTENTS: BY PAYER

    1. Aetna
    2. Aetna Better Health of NJ (Medicaid MCO)
    3. Aetna Medicare Advantage
    4. Amerigroup (Medicaid MCO)
    5. AmeriHealth
    6. Cigna
    7. Clover Health (Medicare Advantage)
    8. Horizon
    9. Horizon Medicare Blue
    10. Horizon NJ Health (Medicaid MCO)
    11. Medicare
    12. Oxford
    13. Qualcare
    14. United Healthcare
    15. United Healthcare Community Plan (Medicaid MCO)
    16. United Healthcare Medicare Solutions
    17. Wellcare (Medicaid MCO)
    18. Wellcare (Medicare Advantage)

     

    Aetna

    Aetna Better Health of NJ (Medicaid MCO)

    Medical

    Pharmaceutical

    Aetna Medicare Advantage

    Pharmaceutical

    Amerigroup (Medicaid MCO)

    Medical

    Pharmaceutical

    AmeriHealth

    Medical

    Pharmaceutical

    Cigna

    Medical

    Pharmaceutical

    Clover Health (Medicare)

    Medical

    Pharmaceutical

    Horizon

    Medical

    Pharmaceutical

    Horizon Medicare Blue

    Medical

    Pharmaceutical

    Horizon NJ Health (Medicaid MCO)

    Medical

    Pharmaceutical

    Medicare

    Medical

    Oxford

    Medical & Pharmaceutical

    Pharmaceutical

    Qualcare

    Medical

    United Healthcare

    Medical

    Pharmaceutical

    United Healthcare Community Plan (Medicaid MCO)

    Medical

    Pharmaceutical

    United Healthcare Medicare Solutions

    Medical

    Wellcare (Medicaid MCO)

    Medical

    Pharmaceutical

    Wellcare (Medicare)

    Medical

    Pharmaceutical

     

    >>View Patient Prior Authorization Page


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