| Group and
Individual Products Lists (All products
except Medicare) |
|
|
|
| Medicare Products
List |
|
| |
Previous lists
|
Group and Individual
Products (all products except medicare)
|
Medicare
Products
|
| Medical Pre-authorization
Forms |
| Form |
Description |
Instructions |
Pre-authorization
Form (PDF)
Pre-authorization
Fax Cover Sheet (PDF) (for use when faxing the form) |
This form is used when a condition requires a pre-authorization.
A limited number of services require a pre-authorization.
|
|
Indicate which product the member has. |
|
Indicate if original request. |
|
Complete part II of the form, including all procedures/HCPCS codes
AND diagnosis. |
|
If supporting documentation is attached, mail the form to the addresses
listed. |
|
If no supporting documentation, fax the form (PDF) and cover
sheet (PDF) to the number(s) indicated on form. |
|
Statement of Medical Necessity for Oncotype DX (PDF)
|
This form is used to facilitate medical necessity for Oncotype Dx® Breast Cancer Assay. Codes include S3854 and 84999.
|
Fax completed forms to 1 (800) 453-4341. |
Pharmacy prior authorization
Pharmacy prior authorization information and forms can be found at the RegenceRx Physician Web site.
Investigational services and supplies
Pre-authorization for investigational services and supplies is required. Charges for investigational services and supplies are denied as provider write-offs unless the patient agrees in writing prior to receiving services to be financially responsible for the charges.
|
