CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Chemotherapy Request Form (Medical Benefit)

A faxable form used by providers to request outpatient chemotherapy (medical benefit) for Highmark BlueShield members; collects patient, provider, facility, and clinical regimen information to support authorization and benefit verification.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Chemotherapy Request Form (Medical Benefit)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed Outpatient Chemotherapy Request Form with J-code(s), diagnosis code(s), and supporting clinical documentation to 833-619-5745 to request authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2document pages/chunks

833-619-5745fax number

1required attachment indicator

J-codesbilling fields

Form Submission and Coverage Criteria

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Form submission completeness criteria

Request will be considered when ALL of the following are provided:

Submission completeness: Completed form with member identifiers (Member name, date of birth, UMI), payer type (Medicare or Commercial), requesting physician name and NPI, requesting physician contact and facility details (facility name, facility NPI, facility address), and date of service

Supports administrative processing

Billing information: J-code(s) and diagnosis code(s) entered on the form

Required for claims and benefit verification

Clinical information: Cancer type including histology and stage; current chemotherapy regimen; line of therapy (First, Second, Subsequent); prior therapies with progression or relapse status

Supports medical necessity review; provider must attach pertinent clinical documentation

Attachments and verification: All pertinent clinical information attached and provider has verified member eligibility and benefits

Missing attachments or eligibility verification may delay or prevent authorization

Free-text chemotherapy regimen
[{"text":"Provider must list the member's chemotherapy regimen as free-text for authorization review (what is the member's chemotherapy regimen?),""status":""}]

What the Requesting Provider Must Do

Prior Authorization

Prior authorization submission

Submit this completed Outpatient Chemotherapy Request Form with J-code(s), diagnosis code(s), and supporting clinical documentation via fax to the number listed on the form. Prior authorization is required for outpatient chemotherapy (medical benefit) — include all requested clinical and administrative details to avoid delays.

Fax number: 1-833-619-5745
Include J-code(s) and diagnosis code(s)
Attach supporting clinical documentation (see below)

Documentation Required

Prior therapy documentation

The form asks for prior therapies and line of therapy to document sequencing. Provide a complete prior therapy history including agents/regimens, dates of administration, response (progression/relapse), and which line of therapy this request represents (first, second, subsequent).

List prior systemic therapies and dates
State treatment response (e.g., progression, relapse, stable disease, partial/complete response)
Indicate line of therapy (First, Second, Subsequent)

Documentation Required

Required clinical details

Providers must attach all pertinent clinical information to support medical necessity. This includes cancer type with histology and stage, the specific chemotherapy regimen requested, relevant pathology reports, radiology reports, molecular testing results when applicable, and recent clinic notes documenting performance status and treatment intent.

Cancer type with histology and stage
Requested chemotherapy regimen (agents, doses, schedule)
Pathology and relevant diagnostic reports
Molecular/genomic testing results, if applicable
Recent clinic notes including performance status and treatment intent

Billing Rule

Administrative and billing details

Complete administrative and billing fields on the form to permit processing and claims submission. Missing or incomplete administrative/billing information may delay or prevent authorization and billing. Verify member eligibility and benefits before submission.

Member identifiers: name, date of birth, UMI
Payer type: Medicare or Commercial (check box)
Requesting physician name, NPI, address, office contact phone and fax
Facility name, facility NPI, facility address
Date of service
J-code(s) and diagnosis code(s)

Denial Risk

Missing documentation may delay/deny

Failure to attach the pertinent clinical information listed above or to verify member eligibility and benefits may delay review or result in denial of the chemotherapy authorization.

Attach all requested documentation before faxing the form
Verify member eligibility and benefits through the health plan
Incomplete forms or missing clinical attachments can result in processing delays or denials

Line of Therapy Information

Line of Therapy

Line of therapy options: First, Second, Subsequent (provider to indicate)

Used for sequencing information

Line of therapy — definition and expectations

DefinitionProvider-specified designation of whether the proposed regimen is first-line, second-line, or subsequent therapy for the member.

Options to indicateFirst, Second, Subsequent (provider to indicate on the form)

PurposeUsed to document sequencing information and prior therapies to support medical necessity review.

Required on formThe form asks: 'What line of therapy is this considered (First, Second, Subsequent)?' — providers must answer.

Related documentationProviders should list prior therapies and note progression or relapse status when indicating line of therapy.

Background and Purpose

This form is used to document the clinical and administrative information required to request outpatient chemotherapy under the medical benefit. It collects patient identifiers (member name, date of birth, UMI), payer type (Medicare or Commercial), requesting physician and facility details (including NPI, addresses, and contact numbers), and the proposed service date, J‑code(s), and diagnosis code(s).

Clinically, the form asks providers to specify the member's cancer type with histology, disease stage, the current chemotherapy regimen, the line of therapy (First, Second, Subsequent), and prior therapies including progression or relapse status. Providers are instructed to attach all pertinent clinical documentation and to verify the member's eligibility and benefits prior to submission.

Completed forms and supporting documentation must be faxed to Highmark at 1‑833‑619‑5745 for prior authorization processing; failure to attach required clinical information or to verify eligibility may delay or prevent authorization.

OpenPayer

Outpatient Chemotherapy Request Form (Medical Benefit)

Form Submission and Coverage Criteria

Billing and Diagnosis Codes

What the Requesting Provider Must Do

Regimen Reporting

Line of Therapy Information

Background and Purpose