Fidelis Care Medicaid Form – Fill Out and Use This PDF

Plan Name: Fidelis Care

Plan Phone No. 1-888-343-3547

Plan Fax No. 1-877-533-2405

http://www.fideliscare.org/en-us/providers/pharmacyservices.aspx

NYS Medicaid Prior Authorization Request Form For Prescriptions

Rationale for Exception Request or Prior Authorization - All information must be complete and legible

Patient Information

First Name:

Last Name:

MI:

Male

Female

Date of Birth:

Member ID:

Is patient transitioning from a facility?

Yes

No

____/____/_____

If yes, provide name of facility: _________________________________________________

Provider Information

First Name:

Last Name:

Address:

NPI #:

Phone #:

Fax #:

Office Contact:

Specialty:

Medication/Medical and Dispensing Information

Medication:

Strength:

Frequency:

Qty:

Refill(s):

Case Specific Diagnosis/ICD9:2

Route of Administration: Oral

IM

SC

Transdermal

IV

Other

For physician administered, will this provider be ordering & administering?

Yes

No

If no, supply administering provider:

Please check one of the following:

This is a new medication and/or new health plan

This is continued therapy previously covered by the patient’s current health plan.

for the patient.

If checked, go to question 1

If checked, approx. date initiated _____/_____.

Go to question 5

Drug and Dose	Route	Frequency	Approx. date range therapy		Outcome
			began & stopped
			_____/_____	_____/_____
			_____/_____	_____/_____

Required clinical information: Please provide all relevant clinical information in the box below to support a medical necessity to determine coverage. Refer to health plan coverage requirements for the requested medication (see link above).

Please check here if documentation is attached.

I attest that this information is accurate and true, and that the supporting documentation is available for review upon request of said plan, the NYSDOH or CMS. I understand that any person who knowingly makes or causes to be made a false record or statement that is material to a Medicaid MC claim may be subject to civil penalties and treble damages under both federal and NYS False Claims Acts.

Prescriber’s Signature _________________________________________________________ Date ____/____/______

Information on this form is protected health information and subject to all privacy and security regulations under HIPAA.

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Instructional Information for Prior Authorization

Upon our review of all required information, you will be contacted by the health plan.

When providing required clinical information, the following elements should be considered within the rationale to support your medical necessity request:

OHeight/Weight

OCompound ingredients

OSpecific dosage form consideration

ODrug or Other Related Allergies

Please consider providing the following information as applicable & when available:

OHealthcare Common Procedure Coding System (HCPCS) 4

OTransition of Care Hospital and/or Residential Treatment Facilities Information (contact, phone number, length of stay)

OPatient information (address, phone number)

OProvider information (address, direct electronic contact information, e-mail, etc.)

This form must be signed by the prescriber but can also be completed by the prescriber or his/her authorized agent. The completed fax form and any supporting documents must be faxed to the proper health plan.

Helpful Definitions

1NPI: A national provider identifier (NPI) is a unique ten-digit identification number required by HIPAA for all health care providers in the United States. http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative- Simplification/NationalProvIdentStand/index.html?redirect=/nationalprovidentstand/

2ICD-9: The International Classification of Diseases (ICD) is designed to promote international comparability in the collection, processing, classification, and presentation of mortality statistics http://www.cdc.gov/nchs/icd.htm

3AHFS Drug Information® (AHFS DI®) provides evidence-based evaluation of pertinent clinical data concerning drugs, with a focus on assessing the advantages and disadvantages of various therapies, including interpretation of various claims of drug efficacy. http://www.ahfsdruginformation.com/ DRUGDEX ® is a system within the Micomedex product which provides peer-reviewed, evidence-based drug information including investigational & non prescription drugs. http://www.micromedex.com/

4The HCPCS is divided into two principal subsystems, referred to as level I and level II of the HCPCS:

OLevel I of the HCPCS is comprised of CPT (Current Procedural Terminology), a numeric coding system maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals.

OLevel II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT codes, the level II HCPCS codes were established for submitting claims for these items. http://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html

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