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Click ‘Get Form’ to open the PRIOR APPROVAL REQUEST Member Information in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's first and last name, address, date of birth, and contact numbers. Ensure all fields are legible.
In the 'Insurance Information' section, indicate if the patient has other coverage. If yes, provide the necessary ID numbers and details.
Complete the 'Prescriber Information' section by entering the prescriber's details including their name, address, phone number, and specialty.
Fill out the 'Dispensing Provider/Administration Information' to specify where and how the medication will be administered.
In 'Product Information', indicate that the request is for Lucentis (ranibizumab) along with dosage and directions for use.
Provide diagnosis information by entering primary ICD codes in the designated fields.
Complete any required clinical information based on your specific request type before signing off in the 'Acknowledgement' section.
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The purpose of a cost extension is to provide an orderly completion/closeout of critical activities or a temporary continuation of support to prevent loss of research resources or hardship of personnel. Additional funding support through a cost extension is contingent on the availability of NCATS resources and funding.
What is the Ncats cost extension?
A separate prior approval letter does not need to be sent to NIH. An increase in effort greater than 25% for key personnel should also be reviewed to assess whether there has been a change in the scope of work and the impact, if any, on other sponsored agreements.
How do I request prior approval for HRSA?
Login to EHBs, go to the Tasks tab and select Prior Approvals or go to the menu and select Prior Approvals. Select Create New Prior Approval From the list, locate the applicable grant and select Request Prior Approval. Select the Acknowledgment boxes and select Continue.
Should an unlisted or miscellaneous code be requested, medical necessity documentation and rationale must be submitted with the prior authorization request.
Aug 4, 2025 All prior approval requests must be submitted no later than 30 days before the proposed change and signed by the Authorized Organization Representative (AOR).
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