Adhd Details

Catamaran Prior Auth Form is a form for requesting prior authorization from an insurance company. This form is often used when the patient needs to have surgery and their insurance provider requires such documentation before agreeing to cover the costs of medical care. The Catamaran Prior Auth Form must be completed with accurate information in order for it to be valid, and can then be submitted electronically or by faxing it back in. The Catamaran Prior Auth Form was developed by Catamaran, a healthcare cost management company that specializes in working with employers and health plans on behalf of their employees and beneficiaries.

In the table, there is some information about the catamaran prior auth form. This figure provides information regarding the form's length, finalization duration, and the parts you will be expected to fill.

QuestionAnswer
Form NameCatamaran Prior Auth Form
Form Length2 pages
Fillable?Yes
Fillable fields71
Avg. time to fill out14 min 46 sec
Other nameshtm, NPI, Prescriber, ANTIHYPERKINESIS

Form Preview Example

Prior Authorization Form

Provigil®/Nuvigil®

***All PA forms may be found by accessing https://tnm.providerportal.sxc.com/rxclaim/TNM/PAs.htm***

If the following information is not complete, correct, or legible the PA process can be delayed. Use one form per member please.

Member Information

Last Name

ID Number

Prescriber Information

First Name

Date of Birth

Last Name

NPI#

Phone

First Name

DEA#

Fax

REQUESTED ANTIHYPERKINESIS AGENT

modafinil Nuvigil Provigil

Dose ___________ Directions __________________________________ Qty ________ Duration of Therapy ________

Request to Backdate PA?

Yes

No

If Yes, Requested PA Start Date

 

 

Clinical Criteria Documentation

 

****Do not include documentation that is not requested on this form****

1.What is the diagnosis for this medication?

 

 

Narcolepsy

Obstructive sleep apnea/hypopnea syndrome

 

 

 

 

 

 

 

 

 

 

ADD/ADHD

Shift work sleep disorder

Other

 

 

 

 

 

 

 

 

 

2.

Has the recipient failed an adequate trial of any other stimulant agent(s)?

Yes (please list)

No

 

 

 

 

 

 

Drug 1:_

 

 

 

Strength:

 

 

Quantity:

 

 

Length of trial:

 

 

 

 

 

 

Reason for discontinuation of the drug:

 

 

 

 

 

 

 

 

 

 

 

 

 

Drug 2:_

 

 

 

Strength:

 

 

Quantity:

 

 

Length of trial:

 

 

 

 

 

 

Reason for discontinuation of the drug:

 

 

 

 

 

 

 

 

 

 

 

 

 

Drug 3:_

 

 

 

Strength:

 

 

Quantity:

 

 

Length of trial:

 

 

 

 

 

 

Reason for discontinuation of the drug:

 

 

 

 

 

 

 

 

 

 

 

 

3.

Has the recipient experienced an adverse event, or been intolerant to, a preferred stimulant?

Yes

No

 

 

 

If yes, please list the drug (or drugs) and describe the adverse event or intolerance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Is the patient currently taking the requested medication?

Yes

 

No

 

 

 

 

 

 

 

 

If yes, how long has the recipient been taking the medication?

How has medication been supplied (other insurance, samples provided, patient discharged from hospital on the medication, etc.)?

___________________________________________________________________________________________________________

5.

If request is for Nuvigil, has the patient tried and failed Provigil?

Yes

No Length of trial: _______________________

If no, what is the reason the patient cannot take Provigil? _____________________________________________________________

Complete this section only if diagnosis is obstructive sleep apnea/hypopnea syndrome.

 

6.

Has the recipient had a sleep study?

Yes

No Date of study:

 

 

7.

Does the provider have evidence of documented compliance with a BiPAP or CPAP device?

Yes

 

Total length of therapy?

 

 

 

If no use, why?

 

No

 

----- continued on next page ----

Page 1 of 2

Revised 10/01/12

TennCare Prior Authorization Form: Provigil®/Nuvigil™

– Page 2 –

Patient Name:

 

DOB

 

 

 

 

 

Complete this section only if diagnosis is shift work sleep disorder.

8. Does the patient work a minimum of 6 hours work between the hours of 10 pm and 8 am?

Yes

No

Please note any other information pertinent to this PA request:

Prescriber Signature (REQUIRED):

 

Date:

(By signature, the physician confirms the above information is accurate and verifiable by patient records.)

Fax This Form to: 866-434-5523

Mail requests to: Catamaran PA Department, P.O. Box 3214, Lisle IL 60532-8214

Telephone 866-434-5524

Catamaran will provide a response within 24 hours day upon receipt.

This facsimile transmission contains legally privileged and confidential information intended for the parties identified below.

If you have received this transmission in error, please immediately notify us by telephone and return the original message to P.O. Box 3214; Lisle, IL 60532-8214.

Distribution, reproduction or any other use of this transmission by any party other than the intended recipient is strictly prohibited.

Page 2 of 2

Revised 10/1/2012

How to Edit Catamaran Prior Auth Form

Having the objective of making it as simple to use as it can be, we built this PDF editor. The process of completing the rxclaim can be straightforward in case you follow the following steps.

Step 1: Choose the button "Get Form Here".

Step 2: At this point, you are able to update the rxclaim. This multifunctional toolbar will let you insert, erase, alter, highlight, and undertake other commands to the content material and areas inside the form.

You should provide the following information to fill out the rxclaim PDF:

filling in sxc step 1

Make sure you fill out the Narcolepsy, Obstructive sleep apnea/hypopnea, ADD/ADHD, Shift work sleep disorder, Other, Yes (please list), Drug 1:_, Strength:, Quantity:, Length of trial:, Reason for discontinuation of the, Drug 2:_, Strength:, Quantity:, Length of trial:, Reason for discontinuation of the, Drug 3:_, Strength:, Quantity:, Length of trial:, Reason for discontinuation of the, Yes, If yes, Is the patient currently taking, Yes, If yes, and How has medication been supplied space with the necessary data.

sxc Narcolepsy, Obstructive sleep apnea/hypopnea, ADD/ADHD, Shift work sleep disorder, Other, Yes (please list), Drug 1:_, Strength:, Quantity:, Length of trial:, Reason for discontinuation of the, Drug 2:_, Strength:, Quantity:, Length of trial:, Reason for discontinuation of the, Drug 3:_, Strength:, Quantity:, Length of trial:, Reason for discontinuation of the, Yes, If yes, Is the patient currently taking, Yes, If yes, and How has medication been supplied fields to fill out

The program will ask you to put down some key info to effortlessly complete the area No Length of trial:, Yes, Complete this section only if, Yes, No Date of study:, Yes, Total length of therapy, If no use, ----- continued on next page ----, Page 1 of 2, and Revised 10/01/12.

sxc No Length of trial:, Yes, Complete this section only if, Yes, No Date of study:, Yes, Total length of therapy, If no use, ----- continued on next page ----, Page 1 of 2, and Revised 10/01/12 blanks to complete

The Patient Name:, DOB, Complete this section only if, Yes, Please note any other information, Prescriber Signature (REQUIRED):, Date:, and (By signature field is the place to indicate the rights and obligations of each party.

sxc Patient Name:, DOB, Complete this section only if, Yes, Please note any other information, Prescriber Signature (REQUIRED):, Date:, and (By signature blanks to insert

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