CurrentHealthPartnersPolicy N/A

Site of Care / Pharmacy Administration Prior Authorization Form

A HealthPartners administrative form and instructions requiring specialty pharmacy dispensing for medical injectables provided in outpatient hospital settings and collecting site-of-care justification and prior authorization information for injectable drugs administered in various settings. It governs information collection, specialty pharmacy requirement in outpatient hospitals, temporary 3-month approvals to transition settings, and submission contact/fax details.

Policy Summary

PayerHealthPartners

PolicySite of Care / Pharmacy Administration Prior Authorization Form

Policy CodePolicy N/A

Change TypeAdministrative form / site-of-care requirement

Effective Date

Next Review Date

Key ActionIf outpatient hospital setting is requested, complete questions a–d providing agreement to use a specialty pharmacy, history of severe reactions, medical instability details, and housing/environment risks with supporting rationale.

POLICY UPDATE CHANGES

No material clinical or coverage changes.

3Primary provider actions required (specialty dispensing, site justification, facility data)

3HealthPartners specialty pharmacy options listed

Policy overview and purpose

This administrative form collects information to support HealthPartners’ requirement that medical injectables administered in an outpatient hospital setting be dispensed by a specialty pharmacy, while noting that specialty dispensing is not required if the medication is provided in a clinic setting or by home infusion. The form specifically requests site-of-care justification when outpatient hospital infusion is requested and directs providers to the drug's medical policy posted online for full clinical criteria.

When outpatient hospital infusion is requested the provider must answer all site-of-care questions (a–d), including whether they agree to obtain the medication through a specialty pharmacy and, if so, to which dispenser (HealthPartners specialty pharmacy network: CVS Specialty, Fairview Specialty, Accredo Specialty, or Other). The form also asks whether the patient has had severe or life‑threatening reactions to prior infusions, whether the patient is medically unstable or high-risk requiring continued outpatient hospital oversight, and whether the patient’s home environment precludes home-infusion — with explanations and supporting rationale required.

If the provider does not agree to specialty dispensing but the drug otherwise meets medical necessity, HealthPartners will issue a 3-month approval for the outpatient hospital setting to allow transition and will contact the patient to facilitate selecting an alternative setting or enrollment in specialty dispensing. The form notes that incomplete submissions will be returned and may delay review and provides contact phone numbers and fax numbers for submission and questions.

Specialty pharmacy dispensing & site-of-care rules

Specialty Pharmacy Dispensing Requirement for Outpatient Hospital Setting

HealthPartners requires specialist dispensing when medication is provided in an outpatient hospital setting unless clinic or home infusion setting:

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What providers must do

Documentation Required

Site-of-care justification for outpatient hospital infusions

If outpatient hospital infusion is requested, the provider must complete questions a–d and provide supporting rationale. Questions require: agreement to obtain the medication through a specialty pharmacy; whether the patient has experienced a severe or life‑threatening reaction with prior similar infusions (explain and provide supporting rationale); whether the patient is medically unstable or high‑risk such that outpatient hospital oversight is required (provide details of instability and why office/home infusion are inappropriate); and whether the patient has a high‑risk home environment that precludes home‑infusion services (document specifics such as unstable or unsanitary housing and provide supporting rationale).

Agree to obtain medication through a specialty pharmacy and indicate which dispenser (see specialty pharmacy options).
If prior severe or life‑threatening reaction: explain and provide supporting rationale.
If medically unstable/high‑risk: provide details of instability and why office/home infusion are inappropriate.
If high‑risk home environment: document specifics (e.g., unstable or unsanitary housing) and provide supporting rationale.

Prior Authorization

Specialty pharmacy dispensing requirement

Medications provided in an outpatient hospital setting must be dispensed by a specialty pharmacy. The provider must indicate which dispenser will be used: a HealthPartners specialty pharmacy (CVS Specialty, Fairview Specialty, Accredo Specialty) or Other (specify).

HealthPartners specialty pharmacy options: CVS Specialty, Fairview Specialty, Accredo Specialty.
Option to specify Other specialty dispenser.

Prior Authorization

Three-month interim approval workflow

If the provider does not agree to obtain the medication from a specialty pharmacy but the drug meets all other medical necessity criteria, HealthPartners will issue a 3‑month approval at the outpatient hospital setting to allow time for the patient to transition to an alternative setting. HealthPartners will contact the patient to help select a new preferred setting or enroll in specialty dispensing. The provider will be asked whether they would agree to change the request to a 3‑month duration approval.

HealthPartners will issue a 3‑month approval to allow transition when specialty dispensing is declined but medical necessity is met.
HealthPartners will contact the patient to facilitate selecting an alternative setting or enrolling in specialty dispensing.
Provider will be asked if they agree to change the request to a 3‑month duration.

Documentation Required

Prior authorization submission completeness

Incomplete prior authorization submissions will be returned and may delay review. For professionally‑administered injectable drugs, include required facility information: facility name, address, Federal Tax ID, NPI, and facility type.

Incomplete submissions will be returned and may delay review.
Include administering facility information for professionally‑administered drugs: Name, Address, Federal Tax ID, NPI, Facility Type.

Billing Rule

Submission contact and fax

Fax the completed form to 952-853-8700 or 1-888-883-5434. For questions, call 952-883-5813 or 800-492-7259.

Fax: 952-853-8700 or 1-888-883-5434
Questions: 952-883-5813 or 800-492-7259

Codes referenced by form

No procedure or diagnosis codes specified in formmixed

No codes listed

Document revisions

current statusLatest

No dated revisions provided; document marked as CURRENT. HealthPartners requires medical injectables be dispensed by a specialty pharmacy if provided in an outpatient hospital setting, with exceptions for clinic or home infusion; collects site-of-care justification questions (a–d) and offers a 3-month transition approval if provider declines specialty dispensing. Submission contact/fax and phone numbers provided; incomplete submissions will be returned.