Navigating the healthcare system can be a complex journey, especially when it involves managing chronic conditions that require specialized treatments. For residents of New Hampshire who are covered by Medicaid, accessing certain medications necessitates a carefully structured process to ensure both medical necessity and compliance with state healthcare policies. One such process is embodied in the New Hampshire Magellan Medicaid Prior Authorization Request Form, specifically designed for hyaluronic acid derivatives injections. This form serves as a critical bridge connecting patients, healthcare providers, and insurers, ensuring that the medication prescribed falls within the covered treatments under Medicaid guidelines. It requires detailed patient information, clinical history, and prescriber details to assess the suitability and necessity of the requested medication. The form also inquires about previous treatments and any contraindications, aiming to provide a comprehensive view of the patient’s health state and medical needs. Through sections dedicated to patient demographics, a thorough clinical history, and prescriber credentials, the form demands a high level of detail, facilitating informed decisions about the approval of medication requests. Whether the medication is to be dispensed from a pharmacy or administered by a physician in an office or outpatient setting, the form accommodates both scenarios, with specific directions on where to send the completed document based on the dispensation method. As a cornerstone of patient care management within the New Hampshire Medicaid system, this prior authorization form underscores the commitment to ensuring cost-effective treatment while maintaining high standards of healthcare provision.
| Question | Answer |
|---|---|
| Form Name | Nh Magellan Medicaid Prior Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | pharmacologic, DERIVATIVES, pharnacy, NH |
HYALURONIC ACID DERIVATIVES
INJECTION
New Hampshire Medicaid Prior Authorization Request Form
Fax to Magellan if medication is to be dispensed from a pharnacy
Magellan Fax:
Fax to Schaller Anderson if medication is dispensed/administered by a physician in
the office or outpatient setting:
Schaller Anderson Fax:
Date of Medication Request: |
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Section I: Patient Information and Medication Requested |
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Name (Last, First): _____________________________________________________________________________ |
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NH Medicaid Number: |
____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ |
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Date of Birth: ___ ___ /___ ___ /___ ___ ___ ___ |
Gender: |
Male Female |
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Drug Name: ______________________________________ |
Strength: ____________________________________________ |
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Dosing Schedule: _________________________ ________ |
Length of Therapy: |
From __/__/____ to __/__/____ |
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Number of injections required/requested: ____________________________________________________________________
Section II: Clinical History
1.Patient’s diagnosis for use of this medication (please be complete and use a separate sheet if additional space is required):
_______________________________________________________________________________________________
2. |
Is there evidence of severe bone on bone osteoarthritis of the knee? |
Yes |
No |
3. |
Has there been a trial and failure of (or contraindication to) |
Yes |
No |
If yes, please describe (use a separate sheet if additional space is required): |
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______________________________________________________________________________________________________
4. Has there been a trial and failure of analgesics? |
Yes |
No |
If yes, please describe (use a separate sheet if additional space is required): |
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______________________________________________________________________________________________________
5. |
Is the patient allergic to latex? |
Yes |
No |
6. |
Is there any evidence of infection or skin disease in the area of injection? |
Yes |
No |
If yes, please describe (use a separate sheet if additional space is required):
______________________________________________________________________________________________________
7.Is there any additional information that would help in the
______________________________________________________________________________________________________
SECTION III: PRESCRIBER INFORMATION
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Medicaid Provider ID# ___________________________________ |
Name: ______________________________________ |
NPI: _______________________________________________ |
Phone Number: (__ ___ ___) ___ ___ ___ - ___ ___ ___ ___ Fax Number: (__ ___ ___) ___ ___ ___ - ___ ___ ___ ___
I certify that the information provided is accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to civil or criminal liability.
___________________________________________________
Signature of Prescribing Provider
Revised 8/30/12