NM EviCore Healthcare Drug Prior Authorization free printable template

The state of New Mexico requires the use of this form for pharmacy prior authorization requests and UnitedHealthcare is posting it on their behalf for our providers. Fax form to: 8005402406.(6)* Patient

How to fill out NM EviCore Healthcare Drug Prior Authorization

How to fill out NM EviCore Healthcare Drug Prior Authorization Request

1. Obtain the NM EviCore Healthcare Drug Prior Authorization Request form from the official website or healthcare provider.
2. Fill out the patient’s information, including their name, date of birth, and insurance details.
3. Specify the medication that requires prior authorization and include the dosage and quantity.
4. Provide the medical diagnosis and indication for the medication.
5. Include relevant clinical information, such as previous treatments attempted and their outcomes.
6. Attach any necessary documentation, such as lab results or medical history, to support the request.
7. Review the completed form for accuracy and completeness.
8. Submit the form through the specified method (fax, online portal, etc.) to EviCore Healthcare.

Who needs NM EviCore Healthcare Drug Prior Authorization Request?

1. Patients who require specific medications that are subject to prior authorization.
2. Healthcare providers prescribing medications that are regulated under EviCore Healthcare guidelines.
3. Insurance companies enforcing prior authorization policies for certain drugs.

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What is NM EviCore Healthcare Drug Prior Authorization Request?

The NM EviCore Healthcare Drug Prior Authorization Request is a formal process that requires healthcare providers to obtain approval from EviCore Healthcare before prescribing certain medications. This is designed to ensure that the drug is medically necessary and appropriate for the patient's condition.

Who is required to file NM EviCore Healthcare Drug Prior Authorization Request?

Healthcare providers, including physicians and specialists, who prescribe medications that require prior authorization are required to file the NM EviCore Healthcare Drug Prior Authorization Request.

How to fill out NM EviCore Healthcare Drug Prior Authorization Request?

To fill out the NM EviCore Healthcare Drug Prior Authorization Request, providers must complete the designated form with accurate patient information, medication details, diagnosis, and justification for the treatment. This form can typically be submitted electronically or via fax, following the instructions provided by EviCore Healthcare.

What is the purpose of NM EviCore Healthcare Drug Prior Authorization Request?

The purpose of the NM EviCore Healthcare Drug Prior Authorization Request is to manage and control the use of high-cost medications, ensuring they are prescribed appropriately and are medically necessary for the patients, thereby enhancing the quality of care and reducing unnecessary healthcare costs.

What information must be reported on NM EviCore Healthcare Drug Prior Authorization Request?

The NM EviCore Healthcare Drug Prior Authorization Request must include patient demographics, medication being requested, prescribing physician information, diagnosis code, medical history, and the rationale for the requested medication, along with any relevant clinical information.