Prior Authorization Form

Download a blank fillable Prior Authorization Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Prior Authorization Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Prior Authorization Form
NOTE: Refer to the Provider Manual for additional services requiring prior authorization
Fax form to: 888.647.6152
Reset Form
Percutaneous Left Atrial Appendage Closure (LAAC)
Member
Last name: ______________________________________________
First name: ______________________________________
ID #: ___________________________________________________
DOB: ___________________________________________
Date of service: __________________________________________
Requesting provider: ____________________________________
Phone:
Fax: ____________________
Address: _______________________________________________
Contact name: ____________________________________
Servicing provider: ______________________________________
Facility: ________________________________________
Provider tax ID: __________________________________________
Facility tax ID:
Address: _______________________________________________
Address: ________________________________________
_______________________________________________________
Provider phone: __________________
Fax: __________________
Facility phone: _______________ Fax: _______________
Contact name: ___________________________________________
Contact name: ____________________________________
Primary diagnosis description:
Diagnosis code(s) (ICD-10):
Primary procedure description:
Procedure code(s) (CPT):
Criteria
 (1) Shared decision making interaction with an independent non-interventional physician regarding oral anticoagulation in patients with NVAF prior
to LAAC, using an evidence-based decision tool completed.
Date: __________ Note: Priority Health accepts the following tools:
Ottawa Decision Aids
and
EMMI
 (2) Paroxysmal, persistent or permanent non-valvular atrial fibrillation (AF) or previous history of non-valvular AF
 (3) CHA
DS
VASc score: ________ (check all that apply) Note: maximum score is 9 since age may contribute 0, 1, or 2 points.
2
2
Risk Factor
Score
Congestive heart failure/LV dysfunction
1
Hypertension
1
Age >75
2
Diabetes mellitus
1
Stroke/TIA/thrombo-embolism
2
Vascular disease
1
Age 65–74
1
Sex category (i.e. female sex)
1
Total
 (4) HAS-BLED score: ________ (check all that apply)
Hypertension History
Uncontrolled, >160 mmHg systolic
1
Renal Disease
Dialysis, transplant, Cr >2.6 mg/dL or >200 µmol/L
1
Liver Disease
Cirrhosis or Bilirubin >2x Normal or AST/ALT/Alkaline phosphatase >3x Normal
1
Stroke History
Focal neurologic deficit diagnosed by a neurologist lasting >24 hours caused by
1
intracranial bleeding
Major bleed
Hemorrhage requiring hospitalization or Hb drop >2 g/L or requiring transfusion
1
Unstable/high INRs, Time in Therapeutic Range < 60%
Labile INR
1
Age > 65
1
Medication Usage Predisposing to
Antiplatelet agents (ASA clopidogrel) or NSAIDs
1
Bleeding
≥ 8 drinks*/week
Alcohol or Drug Usage History
1
Total
*drink is defined as 12 fl oz (350ml) beer 5% alcohol, 5 fl oz (150ml) wine 12% alcohol, 1.5 fl oz (45ml) 80 proof distilled spirits 40% alcohol)
 (5) Contraindication to long-term oral anticoagulants (OAC) due to history of internal or external bleeding
Insert bleeding history:
___________________________________________________________________________________________________
 (6) Contraindication to long-term OAC due to high risk for bleeding
Insert contraindication:
___________________________________________________________________________________________________
 (7) Failure of OAC (e.g.embolic event despite adequate anticoagulation)
 (8) Survival expectancy > 2 years
 (9) None of the following contraindications: a) contraindicated/allergic to aspirin, b) unable to take aspirin or warfarin for 45 days, c) history of atrial
septal repair or has an ASD/PFO device, d) implanted mechanical valve prosthesis, e) anticoagulation required for another indication (e.g. DVT,
PE), f) LVEF < 20%, and g) existing pericardial effusion >2mm
Print
***All fields must be complete and legible for prior authorization review***
April 2016

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go