Catamaran Prior Auth Form PDF 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?No
Fillable fields0
Avg. time to fill out30 sec
Other namesNPI, Backdate, TennCare, rxclaim

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

No

 

 

Total length of therapy?

 

 

If no use, why?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

----- 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 Online for Free

This PDF editor was built to be as straightforward as possible. Since you try out the following steps, the procedure for creating the Backdate document will undoubtedly be easy.

Step 1: Get the button "Get Form Here" and then click it.

Step 2: When you get into our Backdate editing page, there'll be lots of the options you can undertake about your template at the top menu.

Complete all of the following sections to create the document:

portion of spaces in providerportal

The application will require you to complete the What is the diagnosis for this, Narcolepsy, ADDADHD, Obstructive sleep apneahypopnea, Shift work sleep disorder, Other, Has the recipient failed an, Yes please list, Drug, Strength, Quantity, Length of trial, Reason for discontinuation of the, Drug, and Strength field.

part 2 to entering details in providerportal

Determine the relevant particulars in the Has the recipient had a sleep, Yes, No Date of study, Does the provider have evidence, Yes, Total length of therapy, If no use why, continued on next page, Page of, and Revised section.

providerportal Has the recipient had a sleep, Yes, No Date of study, Does the provider have evidence, Yes, Total length of therapy, If no use why, continued on next page, Page of, and Revised fields to complete

Within the box TennCare Prior Authorization Form, Patient Name, DOB, Complete this section only if, Does the patient work a minimum, Yes, Please note any other information, Prescriber Signature REQUIRED, Date, and By signature the physician, list the rights and responsibilities of the parties.

Filling out providerportal step 4

Step 3: Press the button "Done". Your PDF form is available to be transferred. You will be able download it to your laptop or send it by email.

Step 4: It is safer to prepare copies of the file. You can rest easy that we won't reveal or see your details.

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