WebbComplete, Download, and Fax the Referral Form. Benefit and Referral Assessment by Our Team of Specialists. Infusion is Scheduled with Patients. Post-Treatment Follow-Up. Referral Process. ... Injectafer ® Referral Form ... Webbto provide Injectafer to any patient under the Patient Assistance Program. If my patient obtains Injectafer via the Patient Assistance Program, I attest that I understand the …
Blue Cross Authorization Requirements & Criteria - BCBSM
WebbClaims. 1500 Medical Claim Form. UB-04 Facility Claim Form. X12 HIPAA Standard Transaction Enrollment Request Form. 835 Transaction Companion Guide. 837 Transaction Companion Guide. Registration Form for Trading Partner Testing. Instructions for Electronic Claim and Trading Partner Testing. WebbInjectafer is injected into your vein to treat iron deficiency anemia in adults and pediatric patients 1 year of age and older. Injectafer should be used only if you have not responded well to treatment with oral iron, or if you are intolerant to oral iron treatment. green lantern hal jordan action figure
INJECTAFER PATIENT ENROLLMENT FORM - DSI Access Central
WebbIf you require a prior authorization for a medication not listed here, please contact UPMC Health Plan Pharmacy Services at 1-800-979-UPMC (8762). If you are unable to locate a specific drug on our formulary, you can also select Non-Formulary Medications, then complete and submit that prior authorization form. A. WebbRevised 05/2024 2 Referral, Prior Authorization and Notification Policy Providers rendering specialty care services are subject to prior authorization requirements for specific items and/or services. Note: A referral does not take the place of prior authorization. Commercial Products Referrals are required for the following plan types. WebbHome Health/Home Infusion Therapy/Hospice: 888-567-5703. Inpatient Clinical: 800-416-9195. Medical Injectable Drugs: 833-581-1861. Musculoskeletal (eviCore): 800-540-2406. Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number, which can be found here. fly fishing resort in montana