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Get Ny Nys Medicaid Prior Authorization Request Form For Prescriptions
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How to use or fill out the NY NYS Medicaid Prior Authorization Request Form For Prescriptions online
Filling out the NY NYS Medicaid Prior Authorization Request Form For Prescriptions online can seem daunting, but with clear guidance, it becomes manageable. This guide will walk you through each step of the process to ensure that your request is completed accurately and efficiently.
Follow the steps to successfully complete the form online:
- Press the ‘Get Form’ button to access the NY NYS Medicaid Prior Authorization Request Form For Prescriptions and open it in your browser.
- In the patient information section, fill in the patient's first name, last name, middle initial, member ID, and date of birth. Indicate the patient's gender and specify if they are transitioning from a facility, providing the facility's name if applicable.
- Next, complete the provider information section. Enter the provider's first name, last name, NPI number, phone number, address, and fax number along with the office contact and specialty details.
- In the medication/medical and dispensing information section, specify the medication name, strength, diagnosis code (ICD9), frequency, quantity of medication, and number of refills. Also, indicate the route of administration from the provided options.
- Answer whether the drug requires dose titration and if it is being used for an FDA approved indication. Provide any necessary details and indicate treatment history with preferred/formulary drugs.
- Include any relevant clinical information to support medical necessity for coverage. Attach documentation if applicable and ensure you check the box indicating that documentation is attached.
- Finally, review the entire form for accuracy. Sign and date the form in the designated area. Once completed, save your changes. You may then download, print, or share the form as needed.
Take the first step now and fill out your documents online!
To contact eviCore for authorization inquiries, you can call 1-844-678-6068. eviCore is a healthcare management service that handles certain prior authorizations related to prescriptions. By reaching out, you can ask questions regarding the NY NYS Medicaid Prior Authorization Request Form For Prescriptions and other related services they offer.
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