Get This Form, Please Contact Nps At 1-800-546-5677 Option 3 Then Option 2 - Duluthmn

Filling out the Coverage Determination Request Form is a straightforward process that allows healthcare providers to request necessary medications for their patients. This guide provides clear instructions on how to complete the form effectively to ensure timely processing.

Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document viewer.
2. Begin with Section One, providing patient information. Enter the patient's name, date of birth, plan name, identification number, and plan number accurately. Ensure all fields are filled to avoid processing delays.
3. In Section One, specify the reason for the request. Choose from options like covering a non-formulary medication, overriding quantity limitations, or other relevant reasons.
4. List the medication name, strength, and SIG (instructions for use) along with the start date of therapy. This section is crucial for determining the necessity of the requested medication.
5. Document past medication trials by filling out the required sections for Trial #1, #2, and #3, including the dates of therapy and reasons for discontinuation. Providing detailed information here can support the necessity of the current request.
6. Detail any contraindications to formulary, alternative, or generic medications in the corresponding section. This information helps in evaluating the appropriateness of alternative treatments.
7. Include the diagnosis or concurrent disease states along with significant lab values, and any documentation regarding medical necessity or off-label use, ensuring that this supports the coverage request.
8. For quantity limit exceptions, specify the dosing schedule and tapering information. This section is important for determining the approval duration.
9. Review the certification statement regarding false claims and ensure all information is true and consistent with the patient's medical records. Provide prescriber details, including name, signature, DEA/license number, NPI number, office phone, and fax information.
10. Finally, ensure all sections are completed. Save the changes, download, print, or share the form as necessary. Submit the completed form by faxing it to NPS at 1-866-632-7946.

Start filling out your form online now to ensure timely processing of your request.