Metroplus Health Plan PDF Details

The Metroplus Health Plan form is a comprehensive document designed for use in the submission of prior authorization requests for prescription medication under the New York State Medicaid program. It serves as a vital tool for healthcare providers in obtaining necessary approval for drug therapies that are not typically covered or require justification due to specific patient conditions. The format of the form mandates detailed input across various sections including patient information, provider details, medication specifics, and the medical rationale for the requested prescription. It emphasizes the need for clarity and completeness, enforcing the submission of legible and accurate details about the patient’s health status, previous treatments, and the necessity for the requested medication. Additionally, it incorporates sections for attesting the medical necessity of the medication, further supported by an attachment option for relevant clinical information and documentation. Instructions laid out in the form guide the prescriber through providing essential data such as diagnosis codes, medication dosage and administration route, and potential adverse reactions or treatment failures with preferred drugs, rationalizing the need for the exception request or prior authorization. Furthermore, it acknowledges the legal requirements, adhering to privacy and security regulations under HIPAA, and outlines the procedure for submission, including the necessity for the prescriber’s signature. The document also conveys instructional information, illuminating on how to substantiate the medical necessity claims with required clinical information, and hints at additional information that may be solicited by the Health Plan to facilitate a determination on the prior authorization request.

QuestionAnswer
Form NameMetroplus Health Plan
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmetroplus tax form, metroplus prior authorization form pdf, metroplus medicaid prior authorization, metroplus form pa for medications

Form Preview Example

Plan Name: ___________________

Plan Phone No. ______________

Plan Fax No.__________________

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:

 

 

Specialty:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI No:1

 

Phone No:

 

Fax No:

Office Contact:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 for the patient. If checked, go to question 1

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

If checked, approx. date initiated _____/_____. Go to question 5

1.Does the drug require a dose titration of either multiple strengths and/or multiple doses per day?

If yes, provide titration schedule: _________________________________________________________

2.Is the drug being used for an FDA approved indication?

2.(a) If the answer to 2 is No, is its use supported by Official Compendia (AHFS DI®, DRUGDEX ®)3

3.Has the patient experienced treatment failure with a preferred/formulary drug(s) or has the patient experienced an adverse reaction with a preferred/formulary drug(s) in the therapeutic class? If yes, complete the following:

Yes

Yes

Yes

Yes

No

No No

No

Drug and Dose

Route Frequency Approx. date range therapy began & stopped

Outcome

_____/_____ _____/_____

_____/_____ _____/_____

4.Is there documented history of successful therapeutic control with a non-preferred/non-formulary drug and transition to a preferred/formulary drug is medically contraindicated? If yes, explain:

Yes No

5. Is this a change in dosage/day for the above medication?

6. Attach relevant lab results, tests and diagnostic studies performed that support use of therapy. Check if attached

Yes No

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.

7. Does the request require an expedited review?

Yes No

Attestation: I attest that this is medically necessary for this patient and that all of the information is accurate to the best of my knowledge. I attest that documentation of the above diagnosis and medical necessity is available for review if requested by the Health Plan. PLEASE NOTE: The Health Plan may request information in addition to what is on the form in order to make a determination.

Prescriber’s Signature _________________________________________________________

Date ____/____/______

 

 

Informaion on this form is protected health informaion and subject to all privacy and security regulaions 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 (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 ® 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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metroplus prior authorization request empty fields to fill in

You have to enter the appropriate details in the Does the drug require a dose, No No No, an adverse reaction with a, Drug and Dose, Route Frequency Approx date range, Outcome, began stopped, Is there documented history of, preferredformulary drug is, Is this a change in dosageday for, Required clinical information, Please check here if documentation, Does the request require an, and Attestation I attest that this is field.

metroplus prior authorization request Does the drug require a dose, No No No, an adverse reaction with a, Drug and Dose, Route Frequency Approx date range, Outcome, began stopped, Is there documented history of, preferredformulary drug is, Is this a change in dosageday for, Required clinical information, Please check here if documentation, Does the request require an, and Attestation I attest that this is fields to complete

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