Highmark Western New York Request Form
This document serves as a request form for outpatient medical injectable treatments, specifically intra-articular hyaluronan injections. It's designed for healthcare professionals to fill out on behalf of eligible patients. Complete this form to ensure proper authorization for treatment.
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How do I fill this out?
Filling out this form requires specific patient information and details regarding treatment. Ensure to gather all necessary clinical data prior to completion. Follow the prompts within the form for accurate submission.
How to fill out the Highmark Western New York Request Form?
1
Identify the member and physician information.
2
Provide accurate diagnosis codes.
3
Select the appropriate drug information.
4
Fill out clinical information related to treatment.
5
Verify eligibility before submission.
Who needs the Highmark Western New York Request Form?
1
Patients seeking intra-articular hyaluronan injections.
2
Healthcare providers needing to authorize treatment for patients.
3
Insurance agents verifying patient eligibility for coverage.
4
Pharmacies processing prescriptions for hyaluronan products.
5
Physical therapists involved in post-treatment assessments.
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What are the instructions for submitting this form?
Submit this completed form by faxing it to Highmark at 1-833-619-5745. Make sure to verify that all sections are filled out accurately to avoid delays. It's also advisable to maintain a copy of the submitted form for your records and follow up with the provider if a response is not received in a timely manner.
What are the important dates for this form in 2024 and 2025?
Check with Highmark's official resources for the latest updates on treatment authorization deadlines. Important changes may occur in early 2024 and 2025, so ensure to stay informed. Contact your provider for the most current information regarding submission timelines.
What is the purpose of this form?
The purpose of this form is to document the medical necessity for outpatient injectable treatments. By using this form, healthcare providers can ensure their patients receive necessary care after adequate evaluation. This form safeguards the authorization process for treatments involving hyaluronan injections, a key component in managing osteoarthritis symptoms.
Tell me about this form and its components and fields line-by-line.
- 1. Member Name: Full name of the patient requesting treatment.
- 2. Date of Birth: Patient's birthdate for identification.
- 3. Requesting Physician's Name: Name of the physician submitting the request.
- 4. Facility: Name of the facility where treatment occurs.
- 5. ICD10 Diagnosis Code(s): Diagnosis codes pertinent to the patient's condition.
- 6. Date of service: Date on which the treatment is expected to occur.
What happens if I fail to submit this form?
Failure to submit this form may result in treatment delays or denial of authorization. It is crucial to provide accurate and complete information to prevent potential issues. Ensure all required sections are filled out correctly.
- Treatment Delay: Patients may experience unnecessary delays in receiving prescribed treatments.
- Insurance Denial: Incorrect information can lead to non-approval of coverage by insurance providers.
- Inadequate Care: Failure to complete the form may hinder proper medical assessment and management.
How do I know when to use this form?
- 1. Request for Treatment: To request authorization for hyaluronan injections for eligible patients.
- 2. Eligibility Verification: To verify a patient's insurance coverage prior to treatment.
- 3. Documentation of Medical Necessity: To justify the treatment recommended by healthcare providers.
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What if I entered incorrect information?
You can re-upload the PDF to make the necessary corrections before saving.
How will I know when to use this form?
This form is specifically for requesting hyaluronan injections for patients diagnosed with osteoarthritis.
Where do I send the completed form?
Fax the completed document to Highmark at the specified number provided on the form.
What if my patient is not eligible for coverage?
Ensure to check for member eligibility based on the outlined factors in the form.
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