Updated June 02, 2022
A Keystone First Prior Authorization Form allows physicians to secure coverage for a non-preferred medication on behalf of their patients.
- Fax: 1 (215) 937-5018
- Prior Authorization Retro Fax: 1 (215) 937-737
- DME Fax: 1 (215) 937-5383
- OB Request Fax: 1 (844) 688-2973
- Phone: 1 (800) 588-6767
How to Write
Step 1 – In the first section of the prior authorization form, you will be asked to provide the following information regarding your facility:
- Facility name
- NPI number
- Tax ID #
- Complete address
- Phone #
- Fax #
Step 2 – Next, you will need to enter the following provider information (this is you):
- Provider’s name
- Keystone First provider ID
- NPI #
- Tax ID #
- Complete address
- Phone and fax #
- Preparer’s name
- Preparer’s phone and fax #
- Date faxed
- Number of pages
Step 3 – In Patient information, you are required to enter the patient’s name, their Keystone First ID number, their date of birth, their eligibility date, and any third-party liability information.
Step 4 – Next, check the appropriate box to indicate the type of request being sent.
Step 5 – In the bottom two windows, submit the following data:
- Date and type of requested service
- Treating physician name and NPI #
- Pending authorization #
- Dx/CPT/HCPC codes
- Referring physician name, NPI #, phone #, and fax #