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Keystone first authorization form 2025

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The document is a Prior Authorization Form for Keystone First, detailing the necessary information required for submitting prior authorization requests via fax. It includes sections for provider and patient information, service details, and various fax numbers for different types of requests.

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Click ‘Get Form’ to open the Keystone First Authorization Form in the editor.
Begin by filling in the facility information, including the facility name, NPI number, Tax ID, address, phone, and fax details. Ensure accuracy as this information is crucial for processing.
Next, provide the provider's details. Enter the provider name, Keystone First provider ID, NPI number, Tax ID, address, phone, and fax. This section identifies who is requesting the authorization.
In the patient information section, input the patient's name, Keystone First ID number, date of birth, eligibility date, and any third-party liability details. Select one of the request types: IP request, OP request, SPU, DME (rental or purchase), OB request or home care.
Complete additional fields such as date of service, requested service details including treating physician's name and NPI number. If applicable, include pending authorization numbers and relevant codes (Dx code(s), CPT code(s) with quantity).
Finally, fill in referring physician details including their name and contact information before reviewing all entries for accuracy.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Should I accept or decline HIPAA authorization?

Keystone First is a Medical Assistance (Medicaid) managed care health plan that was founded by the Sisters of Mercy in 1982 to help people get care, stay well, and build healthy communities. Today, we remain committed to that mission.

What is an authorization to share health information?

The primary purpose of the HIPAA release form is to provide a legal means for individuals to authorize the sharing of their health information. This authorization protects patient privacy while allowing necessary parties access to crucial medical records.

What is a prior authorization request form?

Prior authorization also frequently referred to as preauthorization is a utilization management practice used by health insurance companies that requires certain procedures, tests and medications prescribed by healthcare clinicians to first be evaluated to assess the medical necessity and cost-of-care ramifications

Does Keystone first require prior authorization?

Services that require Prior Authorization by Keystone First VIP Choice. All out-of-network services (excluding emergency services). All inpatient hospital admissions, including medical, surgical, skilled nursing, and rehabilitation.

What is Keystone First authorization for sharing health information?

Your authorization allows Keystone First to share your PHI with the person(s) or organization(s) that you choose. You can also choose to allow the person(s) or organization(s) to share your PHI with Keystone First. You can cancel this authorization at any time by contacting Keystone First.

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