Novoseven Details

If you are like most Americans, you are covered by some form of health insurance. And if you are like most Americans with health insurance, you have to get prior authorization for certain procedures and services. The process of getting prior authorization can be confusing and time-consuming, but it's important to make sure that you do everything possible to get the care that you need. The good news is that there are a number of resources available to help you through the process. This blog post will give you a brief overview of the Healthnet Prior Authorization Form and how to submit it. Stay tuned for future posts on this topic, which will provide more in-depth information about specific aspects of the form.

The table features information regarding the healthnet prior authorization form. Prior to complete the form, it can be worth reading a little more about it.

QuestionAnswer
Form NameHealthnet Prior Authorization Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesNF, EOC, hereof, 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.

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