Fep Clinical Prior Authorization Form

Federal Employee Program (FEP) Service Benefit Plan Coverage ...
Prior Approval Prior Approval for FEP subscribers is required for the following outpatient Tissue Transplants & Clinical Trials (Call 1-800-225-2268 for more information) Federal Employee Program (FEP) ... View Full Source

® PATIENT INFORMATION DRUG AUTHORIZATION FORM Phone: 800-842 ...
CLINICAL INFORMATION Prior Medications (Name, strength, and frequency) (Attach additional pages if needed) Adverse Reaction Treatment Failure Date Started Length of Therapy DRUG AUTHORIZATION FORM CONFIDENTIAL ® PATIENT INFORMATION ... Retrieve Doc

Prior Authorization Form GROWTH HORMONES
Prior Authorization Form GROWTH HORMONES ONLY COMPLETED REQUESTS WILL BE REVIEWED Clinical evaluation notes, Laboratory tests (FSH, LH, TSH, ACTH), Growth Charts and list any other pertinent medication history in the section below ... Get Document

Viscosupplementation Injectable Medication Precertification ...
Viscosupplementation Injectable Medication Precertification Request Page 1 of 2 . Aetna Precertification G. CLINICAL INFORMATION– Required clinical information must be completed in its entirety for all Enter date of last injection from prior series: Patient First Name . Patient ... Retrieve Here

Skilled Nursing Facility/Inpatient Rehabilitation ...
Skilled Nursing Facility/Inpatient Rehabilitation Authorization Request 1 Cameron Hill Circle Chattanooga, TN 37402 . Providers should obtain the above information for the online authorization process. Clinical Information Functional Status Prior to Admission: ... Document Retrieval

PROVIDER INFORMATION PATIENT INFORMATION - Cigna
- Medication Coverage Determination Form - Exception, Prior Authorization or Step Therapy Exception for CIGNA Medicare Services plan members. Failure to complete this form in its entirety may result in an please include clinical reasons for drug, relevant lab values, etc.): ... Fetch This Document

OptumRx Prior Authorization Request Form
Prior Authorization Request Form . Member Information (required) Provider Information Clinical Information (required) What is the patient’s diagnosis? ICD-9/10 Code(s): If the patient is not able to meet the above standard prior authorization requirements, ... Fetch Here

General Medication Coverage Guideline For Medications Which ...
State or federal mandates, e.g., FEP program, may dictate that any drug, device or biological product (e.g. clinical articles from the literature, clinical guidelines, etc.). Fax completed prior authorization request form to 602-864-3126. ... Doc Viewer

Three Ways To Obtain Prior Authorization From MedSolutions ...
Three Ways to Obtain Prior Authorization from MedSolutions for Radiological Services For your convenience, MedSolutions offers three mechanisms to initiate a prior authorization request: by phone, by fax, In addition to the clinical check-off boxes, the online form offers a text field to ... Get Doc

GA STANDARD PREAPPROVAL REQUIREMENTS BLUE CROSS AND BLUE ...
GA STANDARD PREAPPROVAL REQUIREMENTS BLUE CROSS AND BLUE SHIELD OF AIM Specialty Health®, a separate company. Additionally, this review will now take place as a prior authorization. The program applies to local GA • Federal Employee Program® (FEP®), except echocardiograms ... Get Document

HOW DO I COMPLETE THE HIGHMARK BLUE SHIELD AUTHORIZATION FORM
HOW DO I COMPLETE THE HIGHMARK AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION (ADHI) FORM? Section 1: 1. Identify who will be disclosing the information. ... Fetch Full Source

Otezla (for Maryland Only) - Provider.carefirst.com
Prior Authorization Request . Send completed form to: Case Review Unit, CVS Caremark Prior Authorization Fax: 1-866-249-6155. Does the patient have a clinical reason to avoid pharmacologic treatment with methotrexate, cyclosporine or acitretin? ... Content Retrieval

Anthem Blue Cross And Blue Shield In Colorado Uniform ...
UNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM Clinical Criteria for Approval, Including other Pertinent Information to Support the Request, other Medications Tried, Their Name(s), Duration, and Patient Response: For use in clinical trial? ... Read More

Durable Medical Equipment (DME) Authorization Request
Durable Medical Equipment (DME) Authorization Request Please type/print legibly and fax completed form to: Commercial Utilization Management at 1-866-558-0789 OR Clinical Information Include a list of all pertinent information ... Fetch Content

Introducing: Standardized Prior Authorization Request Form
The standardized prior authorization form is intended to be used to submit prior authorizations requests by fax The Prior Authorization Request Form is for use with the following service types: † Any supporting clinical documentation should be submitted in addition to this form for ... Access This Document

Fax Request Form - OrthoNet Home - Orthonet-online.com
Fax Request Form Instructions: 1. Use this form as a Fax Cover Sheet and send all supporting clinical data with this request 2. Please ensure that this form is a DIRECT COPY from the MASTER 3. Please PRINT, in black ink, one ... Retrieve Document

ADHD MEDICATIONS PREAUTHORIZATION REQUEST
Members under 18 years of age do NOT require Prior Authorization . This form is for prospective, concurrent, and retrospective reviews. Clinical Review Department . 1305 Corporate Center Drive . Eagan, Minnesota 55121 . ... Retrieve Full Source