INTRA ARTICULAR HYALURONAN INJECTIONS PRIOR REVIEW 2026

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The document is a faxback form for requesting prior review and certification of intra-articular hyaluronan injections for patients. It requires information from the prescriber, including their details, patient information, requested medication, diagnosis code, and previous treatments. The prescriber must certify the accuracy of the provided information and understand that BCBSNC may verify it through medical records.
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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering your Prescriber Name and NPI in the designated fields. Ensure that the NPI is marked as required.
  3. Fill in your contact information, including phone number, address, city, state, and zip code. This information is crucial for processing.
  4. Next, provide the Patient Name and their Date of Birth. Select the appropriate gender option.
  5. Indicate the requested drug by checking either 'Preferred' or 'Non-preferred' options for Intra-Articular Hyaluronan Injection.
  6. Complete the Diagnosis Code and Injection Location fields accurately to avoid delays.
  7. Answer the questions regarding previous medications tried and whether the patient is currently receiving treatment with a non-preferred injection.
  8. Finally, certify your request by signing and dating at the bottom of the form before submission.

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, Synvisc, and Synvisc One are preferred products and will be covered without prior authorization. 4. A trial and failure of AND Synvisc/Synvisc One will be required prior to coverage of a non- preferred product UNLESS the patient is currently established on a non-preferred product.
Prior Authorization for Certain Hospital Outpatient Department (OPD) Services Blepharoplasty. injections. Panniculectomy. Rhinoplasty. Vein ablation.
The knee is wiped down with a disinfectant, such as alcohol or iodine. The patient is asked to relax the leg muscles; this will facilitate a successful injection and may also make the injection less painful. The doctor may administer a local anesthetic, such as lidocaine, to numb the area.
You may feel sore at the injection site for the next 2-4 days. For the first 24 hours, you may apply ice (wrapped in a cloth) to the site for 20 minutes on and then 20 minutes off to decrease pain. After 24 hours, you may use heat, if needed. Keep taking your pain medicine as prescribed.
All requests for viscosupplementation with Hyaluronic Acid will require use of or Synvisc/Synvisc One. No other Hyaluronic Acid preparation will be covered. 4. , Synvisc and Synvisc One are covered without prior authorization.

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