Amerihealth Caritas Iowa Request For Prior Authorization

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AmeriHealth Caritas Iowa

Request for Prior Authorization

Miscellaneous

One drug per form only

Form applies to IA Health Link and hawk-i plans.

Please print – accuracy is important.

Fax completed form to 1-855-825-2714. Provider Help Desk: 1-855-328-1612.

Patient name:

AmeriHealth Caritas Iowa member ID #:

Patient address:

DOB:

Provider ID/NPI:

Prescriber name:

Phone:

Prescriber address:

Fax:

Pharmacy name:

Address:

Phone:

Prescriber must complete all information above. It must be legible, correct, and complete or form will be returned.

Pharmacy NABP or NPI:

Pharmacy fax:

NDC:

Please note: AmeriHealth Caritas Iowa uses Iowa Medicaid Enterprise criteria. For complete criteria, please consult

Drug Name:

Dosage Instructions:

Strength:

Quantity:

Days Supply:

Length of Therapy on Prescription (Date Range):

Diagnosis:

Previous therapy (include drug name(s), strength and exact date ranges):

Pertinent Lab Data:

Other medical conditions to consider:

Possible drug interactions/conflicting drug therapies:

Attach lab results and other documentation as necessary.

By signing this document, I attest that the information contained herein is true and accurate to the best of my knowledge and belief. By submitting this

form, I acknowledge that I am submitting a request for authorization of health care services, and I agree to abide by and adhere to established federal and

Iowa fraud, waste and abuse (FWA) rules and regulations and to remain in compliance with AmeriHealth Caritas Iowa’s Program Integrity rules. I further

acknowledge that any claim I submit is subject to investigations, review or audit as determined by AmeriHealth Caritas Iowa. I further acknowledge that an

authorization is not a guarantee of payment.

Prescriber signature:

Date of submission:

(Must match prescriber listed above.)

Important note: In evaluating requests for prior authorization the consultant will consider the treatment from the standpoint of medical necessity

only. If approval of this request is granted, this does not indicate that the member continues to be eligible for Medicaid. It is the responsibility of

the provider who initiates the request for prior authorization to establish by inspection of the member’s Medicaid eligibility card and, if necessary

by contact with the county Department of Human Services, that the member continues to be eligible for Medicaid.

Check to confirm your version of this form.

ACIA-1622-64 (Rev. 3/16)