Read Microsoft Word - 3412 Medical Prior Auth 12271 page 1.doc text version

Medical Prior Authorization Request Form

Fax to: 888-415-9055

Today's date / /

Clinically Urgent Routine

Please note: This form can be used for medications that are supplied by the office/facility and billed as a medical benefit along with an administration code (if necessary). This form should not be used for outpatient pharmacy benefit or specialty pharmacy benefit prior authorization requests. Please visit www.network-health.org to find the appropriate pharmacy form.

Member information Please verify the member's eligibility before rendering services.

Member name Member address City Plan type Network Health Together® (MassHealth) Network Health Extend (Medical Security Program) Member ID # Member phone State ZIP DOB

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Network Health Forward® (Commonwealth Care)

Referring provider information

Provider name NPI # Network Health provider ID # or billing ID # Provider phone Provider address City State ZIP Provider fax Tax ID # -

Treating provider information

Specialist name Network Health provider ID # or billing ID # Specialist address City Specialist phone Contact name Contact phone Contact fax Specialist fax Specialty State ZIP Tax ID #

Reasons for prior authorization request Please check all that apply.

Administer injectable drug at office or facility (have own supply) Other Please specify. Please provide appropriate CPT code(s) below and number of units requesting for time frame (if applicable). CPT code and description Number of units requesting for time frame (if applicable)

Approved medical authorization valid for 90 days from date of issue unless otherwise specified.

3412 12271

Network Health

Form available at www.network-health.org Page 1 of 2

Phone: 888-257-1985

Medical Prior Authorization Request Form

Fax to: 888-415-9055

Diagnosis

ICD-9 code Primary diagnosis Secondary diagnosis

Requested services

Number of visits requested First date of services / 1 2 3 or Other Please describe. Appointment not yet scheduled

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Drug information

Drug name/strength requested NDC # Dose and frequency of administration J-code requested and description Number of J-code units requesting for time frame

Additional clinical information

Please document what other medications member has tried or failed, or please provide documentation of clinical inappropriateness with other medications for the treatment of this diagnosis. You can provide a copy of a chart/progress note, if necessary.

3412 12271

Network Health

Form available at www.network-health.org Page 2 of 2

Phone: 888-257-1985

Information

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