Prior Authorization Form - Priorityhealth

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Prior Authorization Form
NOTE: Refer to the Provider Manual for additional services requiring Prior Authorization
Reset Form
Fax Form To: 616 942-0024
General Genetic Testing
(including Breast and Ovarian Cancer Screening)
Please refer to
Genetics: Counseling, Testing and Screening Medical Policy #91540
for additional information.
Member:
Date: __________________
Last name: ______________________________________________
First name: ______________________________________
Address: _________________________________________________________________________________________________
ID #: ___________________________________________________
DOB: ___________________________________________
Provider:
Name of provider ordering testing: _________________________________________________ Tax ID: ____________________
Contact name: __________________________________________
Phone: __________________ Fax: __________________
Patient Counseling* (must be completed prior to request):
Name of certified *genetic counselor or medical geneticist: __________________________________________________________
Clinic/Facility: _________________________________________________________ Date of counseling: __________________
Contact name: __________________________________________
Phone: ___________________ Fax: __________________
*See
Genetics: Counseling, Testing, Screening Medical Policy #91540
for specific test criteria and genetic counseling
requirements.
Test Requested:
Name of specific test(s):
CPT code(s): ______________________________________________________________________________________________
ICD-9 code(s): _____________________________________________________________________________________________
Directed To:
Facility/Laboratory: _______________________________________
Tax ID#: ________________________________________
Address: _________________________________________________________________________________________________
Contact name: ___________________________________________
Phone: ___________________ Fax: __________________
Member’s personal clinical history related to testing being requested:
Required supportive documentation must include summary notes from a board certified genetic counselor or medical geneticist (not
affiliated with the testing lab) and pedigree.
Family history related to testing being ordered if applicable (please indicate if relationship to member
is maternal or paternal, i.e. maternal aunt, paternal cousin):
Relationship:
Diagnosis:
Age at time of diagnosis __________
Relationship:
Diagnosis:
Age at time of diagnosis __________
Relationship:
Diagnosis:
Age at time of diagnosis __________
Relationship:
Diagnosis:
Age at time of diagnosis __________
Other relevant information related to testing being ordered:
Continued on next page
Page 1 of 2
May 2014
Prior Authorization Form
NOTE: Refer to the Provider Manual for additional services requiring Prior Authorization
Reset Form
Fax Form To: 616 942-0024
General Genetic Testing
(including Breast and Ovarian Cancer Screening)
Please refer to
Genetics: Counseling, Testing and Screening Medical Policy #91540
for additional information.
Member:
Date: __________________
Last name: ______________________________________________
First name: ______________________________________
Address: _________________________________________________________________________________________________
ID #: ___________________________________________________
DOB: ___________________________________________
Provider:
Name of provider ordering testing: _________________________________________________ Tax ID: ____________________
Contact name: __________________________________________
Phone: __________________ Fax: __________________
Patient Counseling* (must be completed prior to request):
Name of certified *genetic counselor or medical geneticist: __________________________________________________________
Clinic/Facility: _________________________________________________________ Date of counseling: __________________
Contact name: __________________________________________
Phone: ___________________ Fax: __________________
*See
Genetics: Counseling, Testing, Screening Medical Policy #91540
for specific test criteria and genetic counseling
requirements.
Test Requested:
Name of specific test(s):
CPT code(s): ______________________________________________________________________________________________
ICD-9 code(s): _____________________________________________________________________________________________
Directed To:
Facility/Laboratory: _______________________________________
Tax ID#: ________________________________________
Address: _________________________________________________________________________________________________
Contact name: ___________________________________________
Phone: ___________________ Fax: __________________
Member’s personal clinical history related to testing being requested:
Required supportive documentation must include summary notes from a board certified genetic counselor or medical geneticist (not
affiliated with the testing lab) and pedigree.
Family history related to testing being ordered if applicable (please indicate if relationship to member
is maternal or paternal, i.e. maternal aunt, paternal cousin):
Relationship:
Diagnosis:
Age at time of diagnosis __________
Relationship:
Diagnosis:
Age at time of diagnosis __________
Relationship:
Diagnosis:
Age at time of diagnosis __________
Relationship:
Diagnosis:
Age at time of diagnosis __________
Other relevant information related to testing being ordered:
Continued on next page
Page 1 of 2
May 2014
Prior Authorization Form
NOTE: Refer to the Provider Manual for additional services requiring Prior Authorization
Fax Form To: 616 942-0024
General Genetic Testing
(including Breast and Ovarian Cancer Screening)
Please refer to
Genetics: Counseling, Testing and Screening Medical Policy #91540
for additional information.
Member:
Last name: ______________________________________________
First name: ______________________________________
ID #: ___________________________________________________
Notes:
1. Completion of risk category does not necessarily mean testing is appropriate or will be automatically approved. Completion of
Prior Authorization Form does not guarantee payment. Payment of covered services is subject to the provider’s contract, the
member’s eligibility on the dates of service rendered, and specific provisions of the member’s health benefits plan. If prior
authorization is not obtained, member may be liable for the cost of the testing.
2. Members who seek coverage for genetic testing for the benefit of OTHER family members that do not also have Priority Health
insurance must seek reimbursement of payment from the OTHER family member’s insurance carrier.
3. A 3-generation pedigree must be appended to this request. Documentation of specific cancer diagnosis in the proband(s) and
pertinent medical records as well as a letter of medical necessity may be required prior to authorization.
4. Genetic Counseling must be done prior to testing by a board certified *Genetic Counselor or Geneticist that is
independent of the laboratory performing the testing.
* Genetic counselors are defined by the plan as American Board of Medical Genetics or American Board of Genetic Counseling
certified physicians or masters or doctorate level-trained genetic counseling professionals who have received formal training in
genetics and genetic counseling from an accredited institution.
Patient Education*:
Consistent with the 1997 National Institute of Health Consensus Statement on guidelines for care of patients with BRCA1 and
BRCA2 mutations and American College of Medical Genetics guidelines, genetic counseling should occur both prior to and after
testing. Also, prior to testing and follow-up treatment, the patient must give informed consent in accordance with applicable law.
Consistent with such guidelines, informed consent discussions should include at least the following:
1. Clarification of the patient’s increased risk status
2. Explanation of how genetics affects cancer susceptibility
3. Potential benefits, risks, limitations of (and alternatives to) testing
4. Possible outcomes of testing (e.g., positive, negative, or uncertain test results)
5. Limited data regarding efficacy of methods for early detection and prevention
6. Possible psychological and social impact of testing
*Health care practitioners in the State of Michigan must follow state law regarding informed consent for predictive genetic testing.
(Michigan State Law. 333.17020 Genetic test; informed consent.
http://www.legislature.mi.gov/(S(bcot2wnj3puzmg550rnzukyf))/mileg.aspx?page=getobject&objectname=mcl-333-17020
By signing this form, I certify that the member listed above has been given informed consent in accordance with the guidelines and
risks above and that the results will be used to direct the medical management of this patient.
Physician name: _____________________________________ Physician signature: _____________________________________
*Certified genetic counselor / geneticist name: ____________________________________________________________________
Phone: ______________________
Contact name: ________________________________
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May 2014

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