Get the free NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form - dhhs nh

This form is used to request prior authorization for non-preferred NSAID medications for patients under NH Medicaid, including necessary clinical history and prescriber certification.

How to fill out nh medicaid prior authorizationnon-preferred

How to fill out NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form

1. Obtain the NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form from the NH Department of Health and Human Services website or your healthcare provider.
2. Complete the patient information section, including the patient’s name, date of birth, and Medicaid ID number.
3. Provide the prescribing physician's information, including name, contact details, and NPI number.
4. Fill in the details of the non-preferred medication, including the name of the drug, dosage, and quantity prescribed.
5. Include relevant clinical information that justifies the need for the non-preferred drug, such as medical history, previous therapies tried, and outcomes.
6. Attach supporting documents such as lab results or notes from consultations that strengthen the justification.
7. Review the completed form for accuracy and completeness.
8. Submit the form via fax or through the online portal, ensuring to retain a copy for your records.
9. Await a response from NH Medicaid regarding the approval or denial of the prior authorization request.

Who needs NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form?

1. Patients who are prescribed non-preferred medications under the NH Medicaid program.
2. Healthcare providers looking to obtain coverage for non-preferred prescriptions for their patients.
3. Pharmacists who need to confirm prior authorization before dispensing certain medications.

People Also Ask about

What is a preferred drug list for Medicaid?

Also known as: out-of-network provider, non-participating provider. A provider who doesn't have a contract with your health insurer or plan to provide services to you. You'll generally pay more to see a non-preferred provider than to see a preferred provider.

What does non preferred drug mean Medicaid?

Non-Preferred Drug means a drug on the MTUS Drug List which is designated as requiring authorization through prospective review prior to dispensing the drug.

What is my NH Medicaid provider number?

How to Enroll Apply for NH Medicaid. Visit NH Department of Health and Human Services (DHHS) website . Click the "Apply Now" link as a new client who is applying for Medical Coverage. Choose a plan. - Call: 1-844-ASK-DHHS (1-844-275-3447) Receive a welcome packet from your plan. Enjoy your new benefits!

What does non-preferred mean in insurance?

If your plan has “preferred in-network pharmacies,” they may save you money on your out-of-pocket drug costs (like a copayment or coinsurance) because they have agreed to charge less than other pharmacies in your plan's network.

What does it mean when a drug is non-preferred?

A PDL is a list of medications that Medicaid will cover the cost for without the need to request a prior authorization (PA). PDLs are comprised of medications that either are generic formulations or are the result of price negotiations between the pharmaceutical companies and Medicaid.

What is New Hampshire Medicaid called?

Call the NH Medicaid Provider Call Center if you have questions while doing your Revalidation: 866- 291-1674.

For pdfFiller’s FAQs

What is NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form?

The NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form is a request submission needed to obtain prior authorization for medications that are not preferred on the NH Medicaid formulary. It ensures that certain criteria are met before the medication is approved for reimbursement.

Who is required to file NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form?

Healthcare providers or pharmacies must file the NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form on behalf of patients when a non-preferred medication is prescribed that requires prior authorization.

How to fill out NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form?

To fill out the NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form, providers must complete patient information, provide details about the medication prescribed, document the medical necessity, and include any relevant clinical information or previous treatment history.

What is the purpose of NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form?

The purpose of the NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form is to ensure that prescribed medications are medically necessary and appropriate for the patient's condition before they are authorized for Medicaid reimbursement.

What information must be reported on NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form?

The NH Medicaid Prior Authorization/Non-Preferred Drug Approval Form must include patient demographic information, the prescribing provider’s details, the specific medication requested, diagnosis codes, clinical information supporting the need for the medication, and any past treatment trials relevant to the request.