Nys Medicaid Prior Authorization Request Form For Prescriptions Page 2
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1
2Instructional Information for Prior Authorization
Upon our review of all required information, you will be contacted by the health plan.
When providing required clinical information, the following elements should be considered within the rationale to
support your medical necessity request:
o
Height/Weight
o
Compound ingredients
o
Specific dosage form consideration
o
Drug or Other Related Allergies
Please consider providing the following information as applicable & when available:
4
o
Healthcare Common Procedure Coding System (HCPCS)
o
Transition of Care Hospital and/or Residential Treatment Facilities Information (contact, phone number,
length of stay)
o
Life Situations Information such as foster care transition, homelessness, poly-substance abuse and history
of poor medication adherence
o
Patient information (address, phone number)
o
Provider information (direct electronic contact information: e-mail, etc.)
This form must be signed by the prescriber but can also be completed by the prescriber or his/her authorized agent.
The completed fax form and any supporting documents must be faxed to the proper health plan.
Helpful Definitions
1
NPI: A national provider identifier (NPI) is a unique ten-digit identification number required by HIPAA for all health
care providers in the United States.
Simplification/NationalProvIdentStand/index.html?redirect=/nationalprovidentstand/
2
ICD-9: The International Classification of Diseases (ICD) is designed to promote international comparability in the
collection, processing, classification, and presentation of mortality statistics
3
AHFS Drug Information® (AHFS DI®) provides evidence-based evaluation of pertinent clinical data concerning
drugs, with a focus on assessing the advantages and disadvantages of various therapies, including interpretation of
®
various claims of drug efficacy.
DRUGDEX
System within the Micomedex
product which provides peer-reviewed, evidence-based drug information including investigational & non
prescription drugs.
4
The HCPCS is divided into two principal subsystems, referred to as level I and level II of the HCPCS:
o
Level I of the HCPCS is comprised of CPT (Current Procedural Terminology), a numeric coding system
maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of
descriptive terms and identifying codes that are used primarily to identify medical services and procedures
furnished by physicians and other health care professionals.
o
Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies,
and services not included in the CPT codes, such as ambulance services and durable medical equipment,
prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Because Medicare
and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT codes,
the level II HCPCS codes were established for submitting claims for these items.
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