Recipient And Insurance Information Template - Synagis Service Prior - Authorization - Maryland Medicaid Pharmacy Program
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SYNAGIS
SERVICE PRIOR-AUTHORIZATION
Maryland Medicaid Pharmacy Program
Fax form to: 1-410-333-5398
(
Incomplete forms will be returned)
Recipient and Insurance Information
Recipient Name: _________________________MA #: _______________MCO patient? Yes No
Today’s date:_____________________Date of Service (or date shipped):__________________
Date of scheduled drug injection: ____________ Location: Office Residence Hospital/Clinic
Once prior-authorization (PA) has been issued for the requested specific date of service, the
approved quantity and the approved days supply, providers must resubmit the claim using these exact
same data elements. Changing any of these data elements will result in claim not going through.
Do not use different dates when referring to the same shipment (i.e when date of service could refer to
either the billing date or shipping date, such date must be consistent with provider’s record keeping).
Third Party Liability: List other insurance: __________________________________________
made by
Note: Maryland Medicaid is always the payer of last resort. List units dispensed and payment
other insurance for coordination of benefits:
NDC 60574-4114-01(50mg/0.5ml vial)-Quantity billed=_____Other insurance paid$________
NDC 60574-4113-01(100mg/1ml vial)- Quantity billed=_____Other insurance paid:$________
Refer to back of form for instructions on determination of number of Synagis vials to ship.
Required Documentation of Patient’s Weight History
Documentation of a minimum of 3 prior actual weight measurements is required for the processing of
each Service PA.
Date of Weight Measurement
Actual Weight As Documented in Medical Record
lb. kg
lb. kg.
lb. kg.
lb. kg.
_____________________________________________________,
Date______________
Signature of Medical Staff (CNP, or RN, or MD)
Phone:______________Fax: _______________
I certify to the validity of the patient’s weight data as submitted. Supporting medical documentation is
available in the patient’s medical record for the weights based on which the doses were calculated.
Please print Name:___________________________Title: NCP - MD - RN
Pharmacy where Rx will be filled:_____________________________Phone: ____________________
Contact Person: ______________________Fax: _______________email:_______________________
FOR INTERNAL USE
Reviewer’s Initials: _____
Approved from:____/____/____to _____/____/____
Bill quantity of 0.5 for each 50mg vial and quantity of 1 for each 100mg vial-
th
The Program will never approve quantity of 1 for the 50mg vial. No 6
dose.
Approved Time frame: Oct 23 – Mar 31 - Administration Time Frame: Nov 1–Mar 31
100mg vials-NDC 60574-4113-01 (100mg/ml) = Quantity approved: ______Days Supply______
50mg vials-NDC=60574-4114-01 (50mg/0.5ml) = Quantity approved: ______Days Supply______
Exception Code Overrides:
4701, 4145, 4713 = PA required
4176 = Cost exceeds $2,500- Override needed if >1 vial is being billed (either 50mg or 100mg)
4194 = Therapeutic duplication if both 50mg and 100mg vials billed concomitantly (Provider
may self-override)
4656 = Max quantity exceeds/Average daily dose exceeds
4452 = Time between Date Written and Date of Service exceeds plan limits
4134, 4135 = Quantity/Days supply exceeds
(October 2012 DHMH)
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