Out-of-area/network providers resources

Below are several forms commonly used by providers.

To help simplify your administrative tasks, you may download and print these forms.

Preauthorization request forms

For services authorized via our musculoskeletal services provider

If the CPT code is listed on the single source preauthorization list and indicates authorization via our musculoskeletal services provider, the following will apply.

Musculoskeletal services post service review process

Please follow the process below for post service surgical reviews:

Step 1
  • Provider has received an authorization for requested CPT code(s).
  • Following the procedure, the CPT code has changed due to performed surgical procedure:
    • CPT code was added to the approved code or instead of the approved code(s).
  • Operative note is required for verification of the additional procedure code(s).
Step 2

Complete the post-service claim review form.

  • Fill in each section, especially the box indicating the update reason.
    • Example: Approval was for CPT 29880 and during surgery, CPT code 29881 was performed.
Step 3

Fax the following information to our musculoskeletal services provider at 717.412.1001.

  • Cover sheet with provider information, including contact name and phone number.
  • Completed post-service claim review form.
  • Operative note: Please make sure the member’s name is listed.
Step 4

Our musculoskeletal services provider will review the faxed information and make a determination within 7-10 business days.

  • Our musculoskeletal services provider will notify the provider of the post service determination.
  • Our musculoskeletal services provider will notify us of the determination.
  • We will verify our records and perform any adjustments, if applicable.
Exclusions

If our musculoskeletal services provider denied the entire surgical request and the procedure was performed, it does not constitute a post service review.

  • Provider can appeal the denied determination.

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Medical Policies

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Single source preauthorization list

Single source preauthorization list

Specialty Injectable drugs may require preauthorization.