CurrentColorado Rocky Mountain Health PlansPolicy N/A

NC Pharmacy Prior Approval Request Form for EPSDT/non-covered services (under 21)

A required submission form and instructions for requesting prior approval for non-covered State Medicaid plan services for recipients under 21 (EPSDT consideration) in North Carolina. The form must accompany a separate Prior Approval request and collect recipient, provider, clinical justification, codes, and supporting documentation.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyNC Pharmacy Prior Approval Request Form for EPSDT/non-covered services (under 21)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionThis form MUST accompany your Prior Approval request for EPSDT consideration and will not be processed if sent alone; submit via provider portal, fax (1-866-940-7328) or mail.

POLICY UPDATE CHANGES

No material clinical/coverage changes.

RequiredForm Requirement

Fax:1-866-940-7328Contact

1-855-258-1593Phone

Policy snapshot

This is the NC Pharmacy Prior Approval Request form for non-covered State Medicaid plan services for recipients under 21 years old. It is used to request consideration under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) for services that are not otherwise covered by the State plan and references federal Medicaid service definitions at 42 CFR 440.1-440.170.

The form MUST accompany a separate Prior Approval request and will not be processed if submitted alone. Submission channels include the provider portal, fax, or mail; you may fax the form to 1-866-940-7328 or call the Pharmacy PA Call Center at 1-855-258-1593 for assistance.

Policy (subject)NC Pharmacy Prior Approval Request Form for EPSDT/non-covered services (under 21)

PayerColorado Rocky Mountain Health Plans

StatusCURRENT

ScopeA required submission form and instructions for requesting prior approval for non-covered State Medicaid plan services for recipients under 21 (EPSDT consideration) in North Carolina. The form must accompany a separate Prior Approval request and collect recipient, provider, clinical justification, codes, and supporting documentation.

Contact Fax/PhoneFax: 1-866-940-7328; Call: 1-855-258-1593

Form RequirementForm required for EPSDT prior approval submissions for recipients under 21

Coverage stance & purpose

This form is informational and administrative in nature: it supports EPSDT consideration by collecting the clinical and administrative information required to review requests for services that would otherwise be non-covered under the State Medicaid plan.

EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) is the Medicaid benefit for recipients under 21 that covers necessary care to correct or ameliorate health conditions; this form gathers the documentation needed to evaluate whether a requested procedure, product, or service meets EPSDT criteria.

Submission requirements and provider actions

Submission requirements for EPSDT Prior Approval requests

Form must accompany a Prior Approval request and include all required clinical and administrative information:

ALL of the following

Complete Recipient Information section (name, DOB mm/dd/yyyy, Medicaid ID, address).
Requestor and Provider Information: Complete Requestor and Provider Information (requestor name, NPI, address; provider name, NPI, address; telephone/fax).
Requested codes: Provide requested procedure/product/service and CPT/HCPCS code(s) when applicable.
Provider relationship: Describe capacity in which provider has treated recipient and duration/nature of care.
Health history: Provide recipient health history including chronic illnesses.
Diagnoses: List recent diagnosis(es) related to the request, onset, course, and current status.
Prior and current treatments: Describe prior and current treatments given for the diagnosis(es), duration, goals, and recipient response.
Clinical justification: Provide description of how requested service will correct/ameliorate condition and how it will improve/maintain health/prevent worsening or additional problems.
Experimental/investigational status: Indicate whether request is for experimental/investigational treatment; if yes, provide name and protocol number.
Safety: Indicate whether the product/service/procedure is considered safe; if no, provide explanation.
Effectiveness: Indicate whether the product/service/procedure is effective; if no, provide explanation.
Alternatives: Indicate whether there are cost-effective alternatives that are similarly medically effective; if yes, specify alternatives and provide evidence.
Expected duration: Provide expected duration of treatment.
Supporting documentation: Attach supporting medical records and evidence-based literature if available.
Signature of requestor with credentials and date.

Prior Authorization

Form submission required with Prior Approval request

This form MUST accompany your Prior Approval request for EPSDT consideration and will not be processed if sent alone. Submit the form with the Prior Approval request via the provider portal, by fax, or by mail.

Provider portal
Fax: 1-866-940-7328
Mail

Documentation Required

Complete clinical documentation required

Submit medical records that support medical necessity. Include treatment history (previous and current regimens, duration, goals, and response), recent diagnoses (onset, course, current status), statements about safety and effectiveness, any alternatives considered with evidence, expected duration of treatment, and evidence-based literature if available.

Treatment history (previous/current regimens, duration, goals, response)
Recent diagnoses with onset, course, and current status
Statements on safety and effectiveness
Alternatives considered and supporting evidence
Expected duration of treatment
Evidence-based literature, if available

Billing Rule

Contact information for PA processing

For assistance with submission or processing, fax the completed form to 1-866-940-7328 or call the Pharmacy PA Call Center at 1-855-258-1593.

Fax: 1-866-940-7328
Pharmacy PA Call Center: 1-855-258-1593

Requested codes

Requested procedure/product/service codes (to be provided by requester)CPT|HCPCS

No codes listed

Regulatory and program context

This administrative form supports prior approval requests for services that are non-covered under the State Medicaid plan but may be considered under EPSDT for recipients under 21. Federal Medicaid service definitions are referenced at 42 CFR 440.1-440.170.

EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) is the Medicaid benefit for recipients under 21 to cover necessary care intended to correct or ameliorate health conditions; the form is used to document recipient information, provider/requestor details, clinical justification, CPT/HCPCS codes when applicable, safety/effectiveness information, alternatives considered, expected duration of treatment, and supporting medical records or literature.

Document changes

N/AStatusLatest

Current administrative form; no documented revisions in brief.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyNC Pharmacy Prior Approval Request Form for EPSDT/non-covered services (under 21)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionThis form MUST accompany your Prior Approval request for EPSDT consideration and will not be processed if sent alone; submit via provider portal, fax (1-866-940-7328) or mail.

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