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INJECTION PRIOR AUTHORIZATION FORM Coverage Criteria is covered for patients with Type 2 diabetes mellitus who have failed to obtain adequate glycemic control on max dose therapy with a thiazolidinedione AND either or AND have an A1C level greater than 6.

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What is prior authorization criteria form?

Prior authorization criteria form is a document that outlines the specific requirements and criteria that must be met in order to obtain prior authorization for a particular medical procedure, treatment, medication, or service.

Who is required to file prior authorization criteria form?

Healthcare providers, such as doctors, hospitals, or clinics, are typically required to file the prior authorization criteria form on behalf of their patients.

How to fill out prior authorization criteria form?

To fill out the prior authorization criteria form, healthcare providers need to provide detailed information about the patient's medical condition, proposed treatment or procedure, supporting documentation, and any other relevant data requested by the insurance provider.

What is the purpose of prior authorization criteria form?

The purpose of the prior authorization criteria form is to review and evaluate the medical necessity, appropriateness, and cost-effectiveness of the requested treatment or service before providing authorization for insurance coverage.

What information must be reported on prior authorization criteria form?

The prior authorization criteria form may require information such as the patient's personal details, medical history, diagnosis codes, treatment plan, healthcare provider's information, supporting clinical documentation, and any other relevant data specified by the insurance provider.