CurrentAvMedPolicy N/A

Medical Drug Medication Precertification Request

This form governs prior authorization (precertification) requests for medications (Medicare Part B) for AvMed members, including submission instructions and required clinical and provider information. It affects providers ordering or administering covered medications and specialty pharmacies submitting requests.

Policy Summary

PayerAvMed

PolicyMedical Drug Medication Precertification Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization including HCPCS code(s), dose, frequency, dates, and supporting clinical documentation (photos to SHPphoto@sentara.com).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare Part Bprogram targeted

Faxprimary submission method

SHPphoto@sentara.comphoto submissions

Allowedexpedited option

Coverage Criteria

This form does not list an explicit set of exclusions. However, all required documentation and chart notes must be provided to support the request; failure to supply complete, correct, and legible documentation may result in denial or delayed authorization.

Procedure and Medication Codes

Procedure and Diagnostic Codesmixed

CPT/HCPCS	CPT/HCPCS code(s)
HCPCS Units	HCPCS Units (i.e., billable units)

Medication Codesmixed

HCPCS	HCPC code(s)
HCPCS Dose/Frequency	Dose (i.e., mg, mL, units); Frequency; Start date; End date

inv-03: HCPCS Units — billable units as reported on form

HCPCS Units definitionHCPCS Units = billable units as reported on the form (entered in the ‘HCPCS Units (i.e., billable units)’ field).

Where recordedEntered alongside CPT/HCPCS code(s) in the Procedure codes/diagnostic services section of the form.

UsageReport units corresponding to the quantity of medication or procedure billed under the HCPCS/CPT code.

Policy Summary

PayerAvMed

PolicyMedical Drug Medication Precertification Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization including HCPCS code(s), dose, frequency, dates, and supporting clinical documentation (photos to SHPphoto@sentara.com).

SourceLink

On This Page

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Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required — prior authorization is required for medications billed under Medicare Part B. Include HCPCS code(s), dose, frequency, start and end dates on the form. Please use the AvMed Medicare Part B Medical Policy located at Prior Authorization - AvMed to view prior authorization criteria for medications.

Include HCPCS code(s), dose (mg, mL, units), frequency, start date, end date.
If using a specialty pharmacy, indicate pharmacy name; check the Proprium Rx Specialty Pharmacy box if applicable.

Denial Risk

Urgent Provider Action

Urgent: If an expedited decision is needed, check the expedite box on the form. CMS defines an expedited request as one where waiting for a standard decision could seriously jeopardize the member's health, life, or ability to regain maximum function.

Check here if expedite is requested: ☐

Documentation Required

Clinical Documentation Required

Clinical documentation must be submitted to support medical necessity. Include relevant chart notes and any required photos. Incomplete, incorrect, or illegible information may delay or result in denial of the request.

Submit required photos to: SHPphoto@sentara.com
All documentation and chart notes must be provided or request may be denied.

Billing Rule

Required Form Fields

Required form fields — complete all member, procedure, medication, and provider fields. Missing fields or documentation may cause denial or delay.

Member information: Name, DOB, ID#, diagnosis code(s).
Procedure/Diagnostic services: CPT/HCPCS code(s), HCPCS units (billable units), description, date(s) of service.
Medication-specific: HCPCS code(s), dose (mg/mL/units), frequency, start date, end date, include medication prior authorization form if applicable.
Provider/Completion: Completed by (name, phone, ext, fax); Ordering/provider performing procedure or ordering medication: name, group name, NPI, tax ID, phone, fax, location of infusion or specialty pharmacy details.

Denial Risk

Incomplete Documentation May Cause Denial

Incomplete documentation may cause denial — if information provided is not complete, correct, or legible, authorization will be delayed or denied.

Ensure all required fields and supporting clinical documentation are included with the request.
If documentation is incomplete the request may be denied.

Definitions

inv-10: Expedited request — definition and when to use expedited processing

Definition (CMS)An expedited request is a request for a determination that must be made quickly because waiting for a standard decision could seriously jeopardize a member's health, life, or ability to regain maximum function.

How to indicate on formCheck the ‘expedite’ box on the form to request expedited processing.

When to useUse for situations where delay from standard processing could seriously jeopardize the member’s health, life, or functional recovery.

Supporting documentationInclude clinical documentation to support medical necessity when requesting expedited review.

OpenPayer

Medical Drug Medication Precertification Request

Coverage Criteria

Procedure and Medication Codes

Provider Actions & Requirements

Background

Definitions

Infusion Center / Specialty Pharmacy