Tufts Interqual Forms 2018 Details

The Tufts Prior Authorization Form, also known as the PAF, is a document that medical professionals use to request authorization from insurance companies for specific treatments or procedures. The PAF must be completed and submitted to the insurance company before any treatment or procedure can be performed. This form is typically used in cases where the patient's insurance coverage has not been determined in advance or when there is a question about whether the procedure will be covered by the patient's insurance plan. The Tufts Prior Authorization Form can be downloaded from the Tufts University website. It is important to note that not all treatments and procedures require prior authorization, so it is important to check with your insurer before completing this form.

This knowledge will help you understand better the details of the tufts prior authorization form before you start filling it out.

QuestionAnswer
Form NameTufts Prior Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namestufts authorization form, tufts interqual forms 2018, tufts medication prior authorization form, tufts health plan prior authorization form

Form Preview Example

Universal Pharmacy Programs Request Form

Pharmacy Utilization Management Department: 705 Mt. Auburn St. Watertown, MA 02472

Commercial: Provider Services: (888) 884-2404 Fax: (617) 673-0988

Tufts Medicare Preferred HMO and PDP & Tufts Health Plan Senior Care Options (HMO SNP)

Provider Relations: (800) 279-9022

Fax to (617) 673-0956

This form is only used for pharmacy requests that require prior authorization review by Tufts Health Plan.

For details of Tufts Health Plan Pharmacy Programs go to tuftshealthplan.com/providers.

For Tufts Medicare Preferred HMO, PDP and Tufts Health Plan Senior Care Options (HMO SNP) members, click here for criteria/request form for Medicare Part B vs Part D Coverage Determinations.

PATIENT INFORMATION

 

 

 

 

PRESCRIBER INFORMATION

 

 

 

 

 

 

Name:

 

Date:

 

 

 

Name:

 

Specialty:

 

Member ID:

 

 

DOB:

 

 

 

Tufts Health Plan Provider ID:

 

__ NPI:

Diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

Fax:

 

 

Relevant Co-morbid Diagnoses:

 

 

 

 

 

Office Contact:

 

 

 

 

 

 

 

 

Additional Comments/History:

 

 

 

 

 

 

 

 

 

Prescriber Signature (required):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUESTED DRUG: Name and Strength:_________________________________________

 

 

THIS SECTION APPLIES TO TUFTS MEDICARE PREFERRED HMO, PDP AND TUFTS

 

Select one:

Dispense As Written

Generic Substitution Authorized

 

 

HEALTH PLAN SENIOR CARE OPTIONS (HMO SNP) ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dosage Form:______________________________________ Quantity:

 

 

 

 

 

1. Does the member’s condition require expedited review (24 Hours)? Yes*

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* By checking the “Yes” box and signing above, I certify that the 72-hour standard review time

 

Duration of requested treatment:

 

 

 

 

 

 

 

 

 

 

 

may seriously jeopardize the life or health of the member or the member’s ability to regain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

maximum function.

 

 

 

 

 

 

 

 

CLINICAL JUSTIFICATION FOR REQUEST (if applicable)

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

2. Does this member reside in long-term care?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prior Medications

 

 

Adverse

 

Treatment

 

Length of Therapy

 

 

Rationale for prior authorization or exception request. Check statement(s) that apply and

 

 

 

 

 

 

 

Reaction

 

Failure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

include supporting documentation under Clinical Justification and Explanation sections on the left:

 

 

 

 

 

 

 

 

 

 

 

 

 

Alternate formulary drug(s) contraindicated or previously tried, but with adverse outcome.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Document drug name, adverse outcome, and, if therapeutic failure, length of therapy on

 

 

 

 

 

 

 

 

 

 

 

 

 

drug.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complex patient with one or more chronic conditions is stable on current drug(s); high risk of

 

EXPLANATION: Describe adverse reaction or treatment failure in detail. If not as

 

 

significant adverse clinical outcome with medication change. Document anticipated

 

 

 

 

 

 

significant adverse clinical outcome.

 

 

 

 

 

 

 

 

effective, length of therapy on each drug and outcome.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical need for different dosage form and/or higher dosage. Document dosage form(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and/or dosage(s) tried and explain medical reason.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Is this a request for a tier exception*?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* All formulary or preferred drug(s) on lower tier(s) contraindicated to the member’s condition or were

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

tried and failed, or not as effective as requested drug. Specialty tier is excluded from tiering

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

exception.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indication:

 

 

 

 

___

 

 

 

 

(attach separate sheet if needed)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 06/2013