Tennessee Prior Authorization Form for General/Non-Preferred Drugs
This form is used to request prior authorization for general and non-preferred drugs for TennCare members. It includes sections for member and prescriber information, drug details, and clinical criteria documentation. The form must be completed and submitted to OptumRx for processing.
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How do I fill this out?
To fill out this form, you'll need to provide detailed information about the member and prescriber, as well as the requested drug and clinical criteria. Make sure all required fields are completed accurately, as incomplete or incorrect information can delay the authorization process. Follow the instructions provided in each section of the form to ensure proper submission.
How to fill out the Tennessee Prior Authorization Form for General/Non-Preferred Drugs?
1
Fill in the member information section with the required details.
2
Complete the prescriber information section accurately.
3
Provide specific details about the requested drug, including dosage, strength, and duration.
4
Document the clinical criteria, including diagnosis and trial results of preferred drugs.
5
Ensure the prescriber signature is included and fax the form to the provided number.
Who needs the Tennessee Prior Authorization Form for General/Non-Preferred Drugs?
1
TennCare members who need authorization for non-preferred drugs.
2
Healthcare providers prescribing non-preferred drugs to TennCare members.
3
Pharmacies processing prescriptions for TennCare members with non-preferred drugs.
4
Care coordinators assisting TennCare members with medication management.
5
TennCare administrative staff overseeing the prior authorization process.
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What are the instructions for submitting this form?
To submit this form, fill out all required sections and ensure the information provided is accurate and legible. Fax the completed form to 1-866-434-5523 or call 1-866-434-5524 for assistance. OptumRx will provide a response within 24 hours upon receipt. It's essential to include all necessary documentation to prevent delays in the authorization process. For any questions or further assistance, contact the provided phone number. Note: The form should be faxed to the specified number, as email and online submission are not mentioned.
What are the important dates for this form in 2024 and 2025?
Revision Date: 03/19/24. Office use only: General_TennCare_2024April.
What is the purpose of this form?
The purpose of this form is to request prior authorization for general and non-preferred drugs under the TennCare program. Prior authorization ensures that prescription medications meet clinically appropriate criteria before being approved for use. This process helps manage medication costs while promoting the safe and effective use of pharmaceutical treatments. Healthcare providers are required to complete and submit this form to OptumRx for review. The form includes sections for member and prescriber information, details about the requested drug, and documentation of clinical criteria. Accurate and complete information is essential to expedite the authorization process and ensure timely access to necessary medications. By utilizing this form, healthcare providers can request approval for drugs that are not preferred or require special consideration. The prior authorization process supports informed decision-making, optimizes patient care, and aligns with TennCare's commitment to providing quality healthcare services to its members.
Tell me about this form and its components and fields line-by-line.
- 1. Member Information: Includes fields for the member's name, date of birth, and OptumRx ID number.
- 2. Prescriber Information: Requires details about the provider, including name, NPI, DEA number, specialty, and contact information.
- 3. Drug Information: Provides fields for the drug name, dosage form, strength, quantity, and duration of therapy.
- 4. Clinical Criteria Documentation: Includes questions about the diagnosis, trial results of preferred drugs, and any adverse events or intolerances experienced.
- 5. Prescriber Signature: Requires the provider's signature to confirm the accuracy of the information provided.
What happens if I fail to submit this form?
Failure to submit this form can result in delays or denial of the requested medication. It's crucial to ensure all required fields are completed and the form is submitted accurately.
- Delayed Medication Approval: Incomplete forms can lead to delays in processing, resulting in postponed access to necessary medications.
- Denial of Prior Authorization: Submitting incorrect or incomplete information can result in the denial of the prior authorization request.
- Increased Administrative Burden: Failure to submit accurate information may require additional follow-up, increasing the administrative workload for healthcare providers.
How do I know when to use this form?
- 1. Non-Preferred Drugs: Request approval for drugs that are not on the preferred list but are necessary for the patient's treatment.
- 2. Clinical Criteria: Document clinical criteria that justify the use of the requested drug.
- 3. Adverse Events: Report adverse events or intolerances to preferred drugs that necessitate the use of a non-preferred drug.
- 4. Continuation of Therapy: Request authorization to continue therapy with a drug that the patient is currently taking.
- 5. Special Circumstances: Provide additional information pertinent to the prior authorization request that may affect the decision-making process.
Frequently Asked Questions
How do I fill out the TennCare Prior Authorization Form?
Complete the member and prescriber information sections, provide details about the requested drug, and document the clinical criteria. Ensure all fields are accurate.
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Are there any guidelines for completing the clinical criteria section?
Provide detailed information about the diagnosis, trial results of preferred drugs, and any adverse events or intolerances experienced by the patient.
What happens if I submit an incomplete form?
Incomplete forms can delay the prior authorization process. Ensure all required fields are filled out accurately before submission.
How soon will I receive a response after submitting the form?
OptumRx will provide a response within 24 hours upon receipt of the submitted form.
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