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Nh medicaid prior authorization form

Nh medicaid prior authorization 2025

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The document is a New Hampshire Medicaid Fee-for-Service Program Prior Authorization Drug Approval Form specifically for Hyaluronic Acid Derivatives Injection. It includes sections for patient and prescriber information, clinical history questions regarding the patient's diagnosis, previous treatments, allergies, and any additional relevant information. The form requires a prescriber's signature to certify the accuracy of the provided information and outlines faxing instructions for medication dispensing.

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Begin with SECTION I: PATIENT INFORMATION AND MEDICATION REQUESTED. Fill in the patient's last name, first name, Medicaid ID number, date of birth, and gender. Specify the drug name, strength, dosing directions, and length of therapy.
Proceed to SECTION II: PRESCRIBER INFORMATION. Enter the prescriber's last name, first name, specialty, NPI number, phone number, and fax number.
In SECTION III: CLINICAL HISTORY, answer questions regarding the patient's diagnosis and treatment history. Provide detailed responses for any trials or failures of previous therapies.
Ensure all sections are completed accurately. Review the certification statement at the end of the form before signing.
Once completed, save your document and utilize our platform's features to fax it directly to Magellan Rx Management or DHHS as needed.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Does NH Medicaid require prior authorization?

Requests for services from a provider, facility, or vendor that is not in the NH Healthy Families network need to be approved by getting a prior authorization. Your healthcare provider can tell you if a medical service or prescription needs prior authorization.

Which types of procedures may need pre authorization under Medicaid?

For example, services that may require pre-certification include outpatient and inpatient hospital services, observation services, invasive procedures, CT, MRI and PET scans, and colonoscopies.

Does Medicaid use prior authorization?

States have authority over prior authorization practices in Medicaid and can implement prior authorization regulations that are stricter than federal requirements (Medicaid Health Plans of America (MHPA) 2023). Medicaid statute provides authority for utilization review in Medicaid ( 1902(a)(30) of the Act).

What is the phone number for Medicaid prior authorization in NH?

How do I request a prior authorization? Requests for prior authorization must be initiated by the prescriber and may be initiated via phone, fax or mail. The Prime Therapeutics phone number is 1-866-675-7755 and the fax number is 1-888-603-7696.

Is prior authorization always required?

Is prior authorization required in emergency situations? No, prior authorization is not required if you have an emergency and need medication. However, coverage for emergency medical costs are subject to the terms of your health plan.