MD DHMH Vivitrol / Campral Prior Authorization 2014 free printable template

Maryland Medicaid Pharmacy Program / Prior Authorization Form Fax: (866) 440-9345 Phone: (800) 932-3918 Date — Patient s Information: Name: DOB: Recipient s Maryland Medicaid Number: Prescriber

How to fill out MD DHMH Vivitrol Campral Prior Authorization

How to fill out MD DHMH Vivitrol / Campral Prior Authorization

1. Obtain the MD DHMH Vivitrol / Campral Prior Authorization form from the official MD DHMH website or your healthcare provider.
2. Fill in patient information including name, date of birth, and insurance details.
3. Provide clinical information such as diagnosis, treatment history, and medical necessity for Vivitrol or Campral.
4. Include supporting documents such as medical records, previous treatment outcomes, and any relevant lab results.
5. Complete the prescriber's section including their name, NPI number, and contact information.
6. Sign and date the application form as required.
7. Submit the completed form through the designated submission method (fax, mail, or online portal).
8. Follow up with the insurance company to confirm receipt and to check on the status of the authorization request.

Who needs MD DHMH Vivitrol / Campral Prior Authorization?

1. Patients seeking treatment for alcohol dependence or opioid dependence who require medication-assisted treatment.
2. Patients whose insurance plan requires prior authorization for Vivitrol or Campral before coverage is provided.
3. Healthcare providers prescribing Vivitrol or Campral for patients who need to ensure that their treatment will be covered by insurance.

People Also Ask about

What is the fax number for Maryland physicians care prior authorization?

Submit all forms and clinical information via fax to 800-953-8856.

Does Maryland Medicaid require a referral to see a specialist?

For some services, you'll need a referral from your primary care provider (PCP) before getting care. You may need to get a referral from your PCP before: Meeting with a specialist.

What is the number for Medicaid preauthorization in Maryland?

If the provider is not enrolled with Maryland Medicaid, the preauthorization request cannot be approved. Should the provider wish to initiate the enrollment process, they must contact Provider Enrollment at 410-767-5340.

How long does it take to get approved for Medicaid in Maryland?

Receive approval for Medicaid. Most applicants who apply online find out immediately if they qualify for Medicaid, but it could take up to 45 days. Once your paperwork has been reviewed and approved, you'll receive a red and white card in the mail within 14 days.

Does MD Medicaid require prior authorization?

Preauthorization is required for some professional services, medical procedures and HCPCS Level II codes. Maryland Medicaid Fee-for-Service will preauthorize services when the provider submits adequate documentation demonstrating that the service is medically necessary.

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What is MD DHMH Vivitrol / Campral Prior Authorization?

MD DHMH Vivitrol / Campral Prior Authorization is a process required by the Maryland Department of Health to obtain approval for the use of the medications Vivitrol and Campral, which are prescribed for the treatment of alcohol and opioid dependence, before they are covered by Medicaid or other insurance.

Who is required to file MD DHMH Vivitrol / Campral Prior Authorization?

Healthcare providers who prescribe Vivitrol or Campral to their patients under Medicaid or other state health plans are required to file for MD DHMH Vivitrol / Campral Prior Authorization.

How to fill out MD DHMH Vivitrol / Campral Prior Authorization?

To fill out MD DHMH Vivitrol / Campral Prior Authorization, providers must complete the designated form provided by the Maryland Department of Health, including patient information, clinical justification for the medication, treatment history, and any other required documents.

What is the purpose of MD DHMH Vivitrol / Campral Prior Authorization?

The purpose of MD DHMH Vivitrol / Campral Prior Authorization is to ensure that the prescribed use of these medications is medically necessary, effective, and appropriate for the patient's treatment plan before Medicaid or insurance coverage is granted.

What information must be reported on MD DHMH Vivitrol / Campral Prior Authorization?

The information that must be reported includes the patient's demographic details, diagnosis, prior treatment history, the rationale for prescribing Vivitrol or Campral, and details about the expected outcomes of the treatment.