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How do I fill this out?
To fill out the form, start by entering the patient's information. Next, provide details regarding the prescriber and the requested medication. Finally, ensure that all relevant questions are answered accurately to avoid delays.
How to fill out the Prior Authorization Medical Necessity Form?
1
Enter the patient's name and insurance details.
2
Fill in the prescriber's information and clinic details.
3
Specify the medication requested along with its dosage.
4
Answer all questions regarding current and past treatments.
5
Submit the completed form via fax or mail.
Who needs the Prior Authorization Medical Necessity Form?
1
Prescribers must complete this form to obtain medication authorization. .
2
Patients needing specific medications that require prior approval. .
3
Healthcare administrators handling prescription requests. .
4
Pharmacists validating insurance coverage for requested prescriptions. .
5
Insurance agents assisting in processing prior authorization.
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What are the instructions for submitting this form?
To submit the completed form, fax it to Horizon Blue Cross Blue Shield at 877.897.8808 or send it via mail to Prime Therapeutics LLC, Clinical Review Department, 1305 Corporate Center Drive, Eagan, Minnesota 55121. Make sure you retain a copy for your records. It is advisable to follow up with a phone call to ensure it was received.
What are the important dates for this form in 2024 and 2025?
The effective dates for this form are from January 1, 2024, to December 31, 2025. Ensure that you are using the most current version of the form for submissions. Regular updates will be posted for any changes in requirements.
What is the purpose of this form?
The purpose of this form is to facilitate the prior authorization process required by Horizon Blue Cross Blue Shield of New Jersey for specific medications. It ensures that prescribers provide all necessary information for the medication review process. This aids in expediting approvals and ensuring patient access to required treatments.
Tell me about this form and its components and fields line-by-line.
- 1. Today's Date: The date on which the form is completed.
- 2. Patient Name: Full name of the patient requiring authorization.
- 3. Prescriber Name: Name of the healthcare provider completing the form.
- 4. Medication Requested: The specific medication being requested for authorization.
- 5. Diagnosis: ICD code and description of the patient's diagnosis.
- 6. Contact Information: Details for contacting the patient and prescriber.
- 7. Fax Number: To send the completed form to the correct department.
What happens if I fail to submit this form?
Failing to submit the form can lead to delays in medication authorization and access for patients. Incomplete information may result in additional requests for clarification, further delaying treatment.
- Delayed Processing: Incomplete forms may postpone the approval process, affecting patient care.
- Return for Additional Info: Forms lacking critical information will be sent back for completion.
- Risk of Non-Approval: Without proper submission, there is a possibility of the authorization being denied.
How do I know when to use this form?
- 1. New Prescriptions: When initiating a new medication requiring authorization.
- 2. Refills: For patients who need ongoing medication refills that necessitate prior approval.
- 3. Treatment Changes: If there is a change in treatment or medication that requires reevaluation.
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