Form Gr 68744 – Fill Out and Use This PDF

The GR-68744 form serves as a crucial document for the precertification notification of viscosupplementation injectable medication, specifically for Aetna members. It facilitates the submission of essential details including treatment commencement, continuation for therapy on knees, patient, insurance, prescriber, diagnosis, clinical information, and prescription requirements to Aetna. This documentation is necessary for obtaining prior authorization for knee osteoarthritis treatments using specific viscosupplementation therapies.

To streamline your treatment process and ensure timely approval, click the button below to fill out your GR-68744 form accurately.

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Form Gr 68744 PDF Details

In the realm of healthcare, managing the complexities of therapy and medication authorization is a task that requires meticulous attention to detail and thoroughness. The GR 68744 form stands as a crucial document for practitioners and patients navigating the process of precertification for viscosupplementation injectable medications under Aetna's guidelines. Located at 503 Sunport Lane in Orlando, Florida, this document is essential for those seeking approval for treatments aimed at alleviating symptoms associated with knee osteoarthritis. It meticulously outlines the need for complete information regarding the patient's medical and insurance details, the prescriber's credentials, and detailed clinical information justifying the request for viscosupplementation therapy. Whether for the initiation or continuation of treatment, the form seeks to streamline the process by requesting data on the patient’s condition, prior treatments, and the specific medication sought, be it Euflexxa, Hyalgan, Orthovisc, Supartz, Synvisc, or Synvisc One. Additional sections emphasize the clinical rationale behind the therapy request, documenting the patient's osteoarthritis symptoms, their response to conservative treatments, and any contraindications to the suggested therapy. The form underscores the collaborative effort between healthcare providers and insurance entities, aiming to ensure that patients receive optimal care tailored to their specific needs through a transparent and efficient authorization process.

Question	Answer
Form Name	Form Gr 68744
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	ICD-9, aetna form gr 68744, Orlando, aetna gr 68744 form printable

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Viscosupplementation Injectable Medication	Aetna Precertification Notification
Viscosupplementation Injectable Medication	503 Sunport Lane, Orlando, FL 32809
Precertification Request	503 Sunport Lane, Orlando, FL 32809
Precertification Request	Phone:	1-866-503-0857
(Please complete all fields and return for precertification requests.)	FAX:	1-888-267-3277

Please indicate: Start of treatment Continuation of therapy:

Right knee

Left knee

both knees Today’s date:

Date of last treatment:

Date needed:

If ASRx is dispensing, ship to:

Doctor’s office

Patient

Other:

Phone:

Dispensing Provider:

Aetna Specialty Pharmacy®

Other:

Phone:

Fax:

TIN:

PIN:

Requesting medication administration code?

Yes

If yes, CPT Code:

20610

Other:

Precertification Requested By:

Phone:

Fax:

A. PATIENT INFORMATION

First Name:

Last Name:

Address:

City:

State:

ZIP:

Home Phone:

Work Phone:

Cell Phone:

DOB:

Allergies:

Email:

Patient Current Weight:

lbs

kgs

Patient Height:

inches or

cms

B. INSURANCE INFORMATION

Aetna Member ID #:

Does patient have other coverage?

Yes

Group #:

If Yes, provide ID#:

Carrier Name:

Insured:

Medicare: Yes

If Yes, provide ID #:

Medicaid:

Yes

If Yes, provide ID #:

C. PRESCRIBER INFORMATION

First Name:

Last Name:

(CIRCLE ONE): M.D. D.O. N.P. P.A.

Address:

City:

State:

ZIP:

Phone:

Fax:

St Lic #:

NPI #:

DEA #:

UPIN:

Provider Email:

Office Contact Name:

Phone:

Specialty (CHECK ONE):

Orthopedic

Primary Provider

Other:

D.DIAGNOSIS INFORMATION - Please indicate primary ICD-9 code and specify any other any other if applicable .

Primary ICD-9:

Other ICD-9 Code:

E.CLINICAL INFORMATION - All clinical questions must be completed for precertification request.


Requesting prior authorization for viscosupplementation therapy for:					Right knee		Left knee		both knees
Please indicate which drug you are requesting: (P is preferred, NP is non-preferred)
		Euflexxa® (P)	Hyalgan® (NP)	Orthovisc® (P)		Supartz® (NP)			Synvisc® (NP)	Synvisc One® (NP)
Yes	No	Does the patient have symptomatic osteoarthritis of the knee?
		If Yes, has this been documented in the patient’s medical record?						Yes	No
Yes	No	Has the patient had a documented failure after at least 3 months of conservative therapy (including physical therapy, pharmacotherapy, i.e.
		non steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and/or topical capsaicin cream) or unable to tolerate conservative therapy
		because of adverse side effects?
Yes	No	Has the patient failed to adequately respond to aspiration and injection of intra-articular steroids?
Yes	No	Does the patient report pain which interferes with functional activities (i.e., ambulation, prolonged standing)?
		If Yes, is the pain attributed to other forms of joint disease?					Yes	No
Yes	No	Does the patient have any contraindications to the injections (i.e., active joint infection, bleeding disorder)?
Yes	No	Does the patient have a contraindication to Euflexxa and Orthovisc?
		If Yes, please explain:

Yes Yes

Yes

	If requesting additional series of injections for patient: Date of last injection from prior series:	/	/
No	Did the patient respond adequately to the prior series of injections?
No	Does the patient’s medical record demonstrate a reduction in the dose of NSAIDs (or other analgesics or anti-inflammatory medication)
	during the period following the previous series of injections?
No	Does the patient’s medical record document significant improvement in pain and functional capacity as the result of the previous injections?

F.PRESCRIPTION – To be completed for precertification request. Prescriptions will be forwarded to Aetna Specialty Pharmacy unless otherwise noted.

MEDICATION - Refer to CPB # 0179	ASRx DISPENSING?		DIRECTIONS
Euflexxa (sodium hyaluronate 1%)

Hyalgan (sodium hyaluronate)

Orthovisc (high molecular weight form of hyaluronic acid)	Yes	No

Supartz (sodium hyaluronate)
Supartz (sodium hyaluronate)

Synvisc (hylan G-F 20)

Synvisc One (hylan G-F 20)

QUANTITY

*If Aetna Specialty Pharmacy is the dispensing pharmacy, patient benefits will be verified before product is shipped.
*If the prescriber is providing the drug, the provider must verify benefits.
Prescriber’s Signature:	Date:	/	/

(Required by law if Aetna Specialty Pharmacy is the dispensing pharmacy.)

Interchange is mandated unless practitioner writes the words “BRAND MEDICALLY NECESSARY” in this space:

Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure, defraud or deceive any insurance company by providing materially false information or conceals material information for the purpose of misleading, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

GR-68744 (9-12)

Form Gr 68744 – Fill Out and Use This PDF

Form Gr 68744 PDF Details

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