Prior Authorization Forms for Imaging Services and Prescription Drugs
Posted on October 18, 2016
Please read the following update related to various Health New England programs and changes that may have an impact on your patients and/or your practice.
Standard authorization forms issued for imaging services and prescription drug prior authorization:
On August 9, 2016, the Division of Insurance released guidance requiring that health plans accept and providers use three standard prior authorization forms in reviewing requests for imaging services and one standard prior authorization form for reviewing requests for prescription drugs, not including hepatitis C treatments or Synagis. The four forms cover the following areas:
- Medication Prior Authorization Requests
- Cardiac Imaging [Myocardial Perfusion Imaging (MPI), Stress Echocardiogram, Multiple Gated Acquisition Scan (MUGA), Transthoracic Echocardiogram (TTE), and Transesophageal Echocardiogram] Prior Authorization Requests
- PET – PET CT Prior Authorization Requests
- CT/CTA/MRI/MRA Prior Authorization Requests
These forms were developed as part of the work of the Mass Collaborative, which includes Health New England along with other health plans, clinicians and hospitals. The forms are available at healthnewengland.org/forms – click Providers tab, select Clinical Request Forms.
If you have any questions about the information in this notice, please contact Health New England Provider Relations at (800) 842-4464, extension 5000. A representative is available Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m.
