CurrentHighmark DelawarePolicy N/A

Outpatient Chemotherapy Form Neny

A faxable outpatient chemotherapy request form for submitting chemotherapy authorization information to Highmark Delaware (medical benefit only). It captures member, provider, facility, service, codes, diagnosis, and clinical rationale details for review.

Policy Summary

PayerHighmark Delaware

PolicyOutpatient Chemotherapy Form Neny

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionFax the completed outpatient chemotherapy request form to 833-619-5745 with member, provider, facility, date of service, J-code(s), diagnosis code(s), and attached clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Required Fax Destination

MultipleRequired Clinical Items

Policy summary

This is a standardized, faxable outpatient chemotherapy request form for medical benefit only. It is used to submit authorization information and captures patient identifiers (member name, date of birth, UMI), provider and facility details (requesting physician, NPI, facility, addresses, contact numbers), date of service, chemotherapy drug codes (J-codes), diagnosis codes, and the clinical rationale required to support prior authorization or utilization review.

Document Metadata

PayerHighmark Delaware

Policy TitleOutpatient Chemotherapy Request Form (Medical Benefit)

Policy Number

StatusCURRENT

Effective Date

Last Review

Next Review

Required Fax DestinationFax to 833-619-5745

Required Clinical ItemsMember identifiers, provider/facility details, date of service, J-code(s), diagnosis code(s), clinical rationale and attached clinical records

Codes captured on the form

J-Codes (submitted on form)HCPCS

J Code(s)

Place to list HCPCS J-codes for chemotherapy drugs being requested

Diagnosis Codes (submitted on form)ICD-10

Diagnosis Code(s)

Place to list ICD-10 diagnosis codes associated with the chemotherapy request

The form expects submission of HCPCS J-code(s) for the chemotherapy drugs being requested and ICD-10 diagnosis code(s) associated with the request; these codes are entered on the fax form in the J Code(s) and Diagnosis Code(s) fields.

Required actions for submission

Prior Authorization

Submit chemotherapy request form via fax

Fax the completed outpatient chemotherapy request form to 833-619-5745 to request medical-benefit chemotherapy; include member, provider, facility, date of service, J-code(s), diagnosis code(s), and attached clinical documentation.

Fax: 833-619-5745
Include member, provider, facility, date of service, J-code(s), diagnosis code(s), attached clinical documentation

Documentation Required

Attach clinical information

Provide cancer type (including histology), disease stage, chemotherapy regimen, line of therapy (first/second/subsequent), prior therapies with progression/relapse details, and attach all pertinent clinical records.

Documentation Required

Verify member eligibility and benefits

Verify the member's eligibility and benefits through the health plan prior to submission.

Operational note: this form is intended specifically for medical-benefit outpatient chemotherapy authorization and submission via fax to 833-619-5745 initiates review. This document is administrative guidance and provided for informational purposes to standardize submission of required data for utilization review.

Purpose and scope

Purpose: a standardized form to request outpatient chemotherapy under the medical benefit. It captures essential data for prior authorization or utilization review including patient identifiers, requesting provider and facility details, date of service, J-code(s) for chemotherapy drugs, diagnosis code(s), and the clinical rationale (cancer type/histology, stage, regimen, line of therapy, prior therapies and progression/relapse) with attached clinical records as applicable.

Scope Summary

Scope / ApplicabilityFaxable outpatient chemotherapy request for medical-benefit chemotherapy to Highmark Delaware; captures member, provider, facility, service date, J-codes, diagnosis codes, and clinical rationale for prior authorization or utilization review

Policy Summary

PayerHighmark Delaware

PolicyOutpatient Chemotherapy Form Neny

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionFax the completed outpatient chemotherapy request form to 833-619-5745 with member, provider, facility, date of service, J-code(s), diagnosis code(s), and attached clinical documentation.

SourceLink

On This Page

OpenPayer

Outpatient Chemotherapy Form Neny

Policy summary

Codes captured on the form

Required actions for submission

Purpose and scope

Document changes