PEEHIP Hemophilia Product Prior Authorization Form and Documentation Checklist
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Prior authorization form and documentation checklist for hemophilia and related clotting factor products for members covered by Blue Cross and Blue Shield of Alabama (PEEHIP). Affects prescribers, dispensing pharmacies, and treating facilities requesting coverage for listed products.
No material clinical or coverage changes in this revision.
Coverage and Submission Criteria
Required submission criteria
Authorization requests should include documentation that all applicable items below have been provided.
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The form does not list any explicit coverage exclusions. It functions as a clinical authorization and documentation checklist, and no section on the form enumerates items that are specifically excluded from coverage.
This document is a prior authorization/data collection form for hemophilia and related clotting‑factor products; it is intended to gather clinical and administrative information (patient/provider details, progress notes, lab results) to support an authorization decision rather than to serve as a standalone coverage policy statement.
Diagnosis and Coding Details
| ICD-10 | ICD-10 code field provided for primary diagnosis (specific codes not listed on form) |
Provider Responsibilities and Submission Requirements
Prior Authorization Required
Prior authorization is required for the hemophilia products listed on the Hemophilia Product Prior Authorization Form. Complete and submit the form in its entirety and fax the form and all required attachments to 1-866-606-6021. All lab results must be faxed in with the request.
- Affected products: Helixate FS; Alphanate; Hemlibra; Wilate; Kogenate FS; BeneFIX; Idelvion; Novoeight; Ixinity; Vonvendi; Recombinate; Rixubis; Afstyla; Xyntha; Alprolix; Adynovate; Coagadex; Eloctate; Corifact; Feiba; Feiba NF; NovoSeven; RT Hemofil M; Koate-DVI; Monoclate-P; Nuwiq; Advate; Obizur; Humate-P; AlphaNine SD; Mononine; Bebulin; Kovaltry; Profilnine; Rebinyn; Tretten
- Fax number for submission: 1-866-606-6021
Prior Therapy Documentation Required
Document prior therapy trials when applicable. For von Willebrand disease (VWD) include documentation of a trial of desmopressin or a contraindication to desmopressin with the reason. For Glanzmann's thrombasthenia include documentation of platelet transfusion trials and response. For patients previously treated with a different factor product, indicate prior product and reason for switching. Include dates and responses for prior immune tolerance induction (ITI) if applicable.
- VWD: desmopressin trial documentation or documented contraindication and reason
- Glanzmann's Thrombasthenia: platelet transfusion trial dates and response
- Prior factor product: name, dates, and reason for switching
- Previous ITI: dates, duration, and patient response
Required Documentation for Submission
Required documentation must accompany the prior authorization form. Incomplete requests risk denial or return-to-provider for additional information.
- Completed Hemophilia Product Prior Authorization Form (all fields)
- Patient demographics and provider/pharmacy contact information
- Progress notes and/or bleeding diaries documenting number and location of bleeds in the past 12 months
- Relevant laboratory results (baseline and most recent factor levels, dates, desired target levels)
- Inhibitor testing results (e.g., Bethesda assay) and documentation of frequency of inhibitor testing for minimally treated patients (<50 exposure days)
- Pharmacokinetic (PK) test results, if performed
- Dosing details: dose (IU), number of doses requested, total dose requested, and dosing instructions
- Procedure information for surgical or dental prophylaxis (type and date of procedure) and place of administration
- For retrospective requests, indicate retrospective status on the form
Missing Documentation — Denial Risk
Requests may be denied or returned to the provider if the form is incomplete or required attachments are missing.
- Missing or incomplete prior authorization form
- Absence of progress notes or bleeding diaries
- Missing lab results or inhibitor testing documentation (e.g., Bethesda assay)
- Missing prior therapy documentation (desmopressin trial for VWD, platelet transfusion for Glanzmann's, prior product trials, ITI details)
Policy Form Background
The form collects detailed clinical data for congenital and acquired bleeding disorders, including diagnoses such as Congenital Hemophilia A/B, Acquired Hemophilia A, von Willebrand disease, factor deficiencies, and Glanzmann's Thrombasthenia. It requests information on disease severity and history (e.g., prior bleeds, number of spontaneous joint bleeds), laboratory results (factor levels, inhibitor testing such as the Bethesda assay), prior treatments and trials (desmopressin for VWD, platelet transfusions for Glanzmann's), treatment status (naïve versus experienced), and additional details for acute bleeding or procedural prophylaxis.
Definitions and Clinical Categories
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