Are you a health care provider enrolled in Nh Magellan Medicaid? If so, you may have encountered the prior authorization form at some point. Prior authorizations are an important part of life as a healthcare provider, and understanding what is required for each step of the process can help make it easier to manage. In this blog post, we will be discussing everything from how to access the Nh Magellan Medicaid prior authorization form to specific tips on filling it out correctly. We hope that these resources prove helpful and give you a better idea of what needs to be done when submitting any type of prior request.
| 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