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Clear Form pegol Prior Authorization Request Form FAX 800-232-0816 For Buy and Bill Physician Administered Drugs Only Patient HPHC member ID Requesting provider Phone Fax Servicing provider Diagnosis ICD 10 code Contact for questions name and phone Projected start and end date for requested treatment Diagnosis Check all that apply Clinical and Dosing Information Check all REQUIRED Check the appropriate treatment Ankylosing Spondylitis Crohn s Disease New Start Drug Na ve Psoriatic Arthritis...

How to fill out harvard pilgrim health care prior authorization form

How to fill out Harvard Pilgrim prior authorization:

1. Obtain the necessary forms: Start by contacting Harvard Pilgrim or visiting their website to obtain the specific prior authorization form. Make sure to download or request the correct form based on the specific service or medication requiring prior authorization.
2. Gather required information: Before starting the form, gather all the necessary information you will need to fill it out. This may include personal information, such as the patient's name, date of birth, and member ID number. You may also need the healthcare provider's information, such as their name, contact details, and National Provider Identifier (NPI) number. Additionally, have the details of the service or medication being requested for prior authorization.
3. Provide patient and healthcare provider details: Begin filling out the form by entering the patient's personal information accurately. Include the name, date of birth, and member ID number as required. Next, enter the healthcare provider's information, ensuring accuracy in their name, contact details, and NPI number.
4. Describe the service or medication: Clearly and accurately describe the service or medication for which you are requesting prior authorization. Include details such as the diagnosis, specific treatment or medication name, dosage, frequency, and anticipated duration of treatment.
5. Attach supporting documentation: Check if any supporting documentation is required for the prior authorization request. This may include medical records, test results, clinical notes, or any other relevant documents that can support the necessity of the requested service or medication. Make sure to attach these documents securely to the form.
6. Submit the form: Once you have completed filling out the form and attaching any required supporting documents, review it thoroughly for accuracy. Double-check that all fields are filled out correctly, and all necessary documentation is attached. After ensuring everything is accurate and complete, submit the prior authorization form. Follow the specific submission instructions provided by Harvard Pilgrim, whether it is mailing the form or submitting it electronically through their online portal.

Who needs Harvard Pilgrim prior authorization:

1. Anyone who intends to access medical services, procedures, treatments, or medications that require prior authorization from Harvard Pilgrim will need to obtain it.
2. Prior authorization is typically required for certain high-cost or specialized services, medications, or treatments that may have alternative options available, or those that have specific criteria that need to be met before coverage is approved.
3. The need for prior authorization is determined by Harvard Pilgrim's policy, which outlines the services or medications that require this additional step. It is important to review the specific plan's policy or contact Harvard Pilgrim for clarification to understand if a particular service or medication requires prior authorization.

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What is harvard pilgrim prior authorization?

Harvard Pilgrim prior authorization is a process required by Harvard Pilgrim Health Care to obtain approval for certain medical services, treatments, or medications before they are rendered or prescribed, ensuring that they are medically necessary and covered under the member's health plan.

Who is required to file harvard pilgrim prior authorization?

Health care providers, such as doctors and specialists, are required to file Harvard Pilgrim prior authorization on behalf of their patients when they recommend services or treatments that require prior approval.

How to fill out harvard pilgrim prior authorization?

To fill out the Harvard Pilgrim prior authorization form, providers need to include patient information, details about the requested service or treatment, clinical rationale for the request, and any relevant medical history or supporting documentation.

What is the purpose of harvard pilgrim prior authorization?

The purpose of Harvard Pilgrim prior authorization is to ensure that the proposed services are medically necessary, appropriate, and cost-effective, thereby helping to manage healthcare costs and improve patient safety.

What information must be reported on harvard pilgrim prior authorization?

The information that must be reported on Harvard Pilgrim prior authorization includes the patient's demographic details, insurance information, the specific service or medication being requested, ICD-10 diagnosis codes, CPT/HCPCS procedure codes, and clinical notes to justify the request.