Prior authorizations and other forms.
|Universal Prior Authorization (PA) Form - All Drugs||10/12/2022|
|Prior Authorization (PA) Form - Benzodiazepines||07/25/2022|
|Prior Authorization (PA) Form - Stimulants||07/25/2022|
Fax Prior Authorizations
Please fax prior authorization requests to the following number:
- Prior Authorization Fax Line
- (858) 357-2612
Telephonic Prior Authorizations or Inquiries
For telephonic prior authorization requests or inquiries regarding a prior authorization call:
- Clinical Call Center
- (844) 336-2676
- (8:00 AM - 7:00 PM EST / 7 days per week)
Denials and Appeals
- A member or an authorized representative may appeal a prior authorization denial.
- The provider may also submit an appeal. If the appeal is on behalf of the member, the provider will require the member's consent.
- Written appeals must be submitted within sixty (60) days of receipt of the denial letter.
Send appeals to the address below:
Attention: Appeals and Grievances Department
MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Court
San Diego, CA 92131
Right to Request External Review
In accordance with 907 KAR 17:035, if a member receives an adverse final decision of a denial (appeal), in whole or in part, of a health service or claim for reimbursement related to this service, providers may request an external independent third-party review. Providers may only do so after first completing an internal appeal with MedImpact. Provider requests for external review will only be considered for dates of service on or after December 1, 2016.
Providers must submit a request for external independent third-party review within 60 days from the date of receipt of the notice. The request must include the provider’s contact information and the reasons the provider believes the decision was incorrect.
MedImpact will confirm receipt of your request for external third-party review within five business days of receiving your request.
As required by 907 KAR 17:035, if you request an external third-party review, MedImpact will forward to the Department for Medicaid Services all documentation submitted by the provider during the appeal/dispute process within 15 business days of receiving your request. Providers may submit the request via fax to MedImpact at 1-858-790-6060. For questions about external reviews, please email firstname.lastname@example.org.
If the decision is upheld by the external independent third-party review, providers have the right to request an administrative hearing in accordance with 907 KAR 17:040 within 30 calendar days of the Department’s written notice.
You must submit your request for administrative hearing to:
Attention: Medicaid Appeals and Reconsiderations
Office of the Ombudsman and Administrative Review
1275 East Main Street, 2E-O
Frankfort, KY 406211