Healthnet Prior Authorization Form PDF Details

Managing the complexities of the healthcare system and ensuring patients receive the medications they need can often involve navigating prior authorization processes set forth by insurance companies. One such process is detailed in the Healthnet Prior Authorization Request Form, a crucial document for healthcare providers prescribing blood clotting disorder medications such as FEIBA VH, FEIBA NF, NovoSeven, and NovoSeven RT. Designed to streamline the review of medication requests, the form requires comprehensive information including patient and prescriber details, diagnosis, and intended treatment plans. Furthermore, it necessitates a detailed account of the patient's medical history and any supporting documentation that could justify the necessity of the requested medication. The form also outlines the procedures for submitting requests for initial or continuing therapy, providing clear directives on how to supply the medication upon approval, whether through Orchard Specialty Pharmacy or a provider/hospital buy and bill system. This detailed document serves as a gatekeeper to ensure that only those who truly need these medications, under careful review by prescribers in collaboration with Healthnet, are approved, thereby managing the pharmacy drug benefit effectively while maintaining a focus on patient care. However, it's important to note that incomplete or illegible information can delay the process, underscoring the importance of accuracy and thoroughness in completing the form. Additionally, the document emphasizes the confidentiality and security of the patient's health information, in accordance with state and federal law, reflecting the care with which this sensitive information must be handled.

QuestionAnswer
Form NameHealthnet Prior Authorization Form
Form Length2 pages
Fillable?Yes
Fillable fields41
Avg. time to fill out8 min 46 sec
Other namestelecopy, bmc standard prior authorization form, NovoSeven, BMCHPQHP

Form Preview Example

PRIOR AUTHORIZATION REQUEST FORM

EOC ID:

BMCHPQHP Blood Clotting Disorder Medications (2)

Policy 9.165

FEIBA VH, FEIBA NF, NovoSeven, NovoSeven RT

Phone: 855-264-4964 Fax back to: 877-503-7231

manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician. Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process.

Patient Name:

Prescriber Name:

 

 

 

 

 

 

Member/Subscriber Number:

Fax:

Phone:

 

Date of Birth:

Office Contact:

 

 

Group Number:

NPI:

State Lic ID:

 

Address:

Address:

 

 

City, State ZIP:

City, State ZIP:

 

 

Primary Phone:

Specialty/facility name (if applicable):

 

 

 

 

 

 

 

Expedited/Urgent

 

 

Drug Name and Strength:

 

 

 

Directions / SIG:

 

 

 

Please attach any pertinent medical history or information for this patient that may support approval. Please answer the

following questions and sign.

Q1. Is the request for initial or continuing therapy? If continuing therapy, include the treatment start date.

Initial

Continuing / Start date (mm/yy):

Q2. Please indicate the patient 's diagnosis below:

Acquired hemophilia

Congenital factor VII deficiency with an acute bleeding episode or increased risk of bleeding due to a clinical situation (i.e. trauma or surgery)

Persistent inhibitors to factor concentrates has developed

Other (please specify):

Q3. Please provide any supporting clinical statements (such as chart notes, lab values, adverse outcomes, treatment failures, or any other additional clinical information) to support an authorization request.

Q4. If coverage of medication is approved, how will this medication be supplied? (Please check one)

Order through Orchard Specialty Pharmacy

Provider/Hospital Buy & Bill

Q5. If Buy and Bill, please provide the following information:

J-codes:______________________________________________________________________

This transmission may contain protected health information, which is transmitted pursuant to an authorization or as permitted by law. The information herein is confidential and intended only for use by the designated recipient who/which must maintain its confidentiality and security. If you are not the designated recipient, you are strictly prohibited from disclosing, copying, distributing, or taking action in reliance on the contents hereof. If you have received this transmission in error, please notify the sender immediately and arrange for the return or destruction of all of its contents. Unauthorized redisclosure of confidential health information is prohibited by state and federal law.

PRIOR AUTHORIZATION REQUEST FORM

EOC ID:

BMCHPQHP Blood Clotting Disorder Medications (2)

Policy 9.165

FEIBA VH, FEIBA NF, NovoSeven, NovoSeven RT

Phone: 855-264-4964 Fax back to: 877-503-7231

manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician. Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process.

Patient Name:

Prescriber Name:

Procedure code(s) for administration of medication:____________________________________

Number of Units and Visits:_______________________________________________________

Date of planned administration:____________________________________________________

___________________________________________________________

_________________________________________

Prescriber Signature

Date

This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reference to the contents of this document is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange for the return of this document.

This transmission may contain protected health information, which is transmitted pursuant to an authorization or as permitted by law. The information herein is confidential and intended only for use by the designated recipient who/which must maintain its confidentiality and security. If you are not the designated recipient, you are strictly prohibited from disclosing, copying, distributing, or taking action in reliance on the contents hereof. If you have received this transmission in error, please notify the sender immediately and arrange for the return or destruction of all of its contents. Unauthorized redisclosure of confidential health information is prohibited by state and federal law.

How to Edit Healthnet Prior Authorization Form Online for Free

This PDF editor makes it easy to prepare documents. You won't have to do much to edit redisclosure files. Merely use all of these actions.

Step 1: The first step should be to select the orange "Get Form Now" button.

Step 2: The instant you get into the EOC editing page, you will see all the actions you may undertake with regards to your file in the upper menu.

Please enter the following details to complete the E, OC PDF:

stage 1 to filling out NovoSeven

The program will need you to submit the part.

step 2 to completing NovoSeven

It is crucial to write down specific information within the area Patient, Name Prescribe, r, Name Prescribe, r, Signature and Date.

Entering details in NovoSeven stage 3

Step 3: Press the button "Done". Your PDF document can be exported. It is possible to obtain it to your pc or send it by email.

Step 4: To avoid any specific troubles in the long run, try to get a minimum of two or three copies of the form.

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