CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Hemophilia Product Prior Authorization Form_Fillable_0918_General

A fillable prior authorization request form for a broad list of hemophilia and related coagulation products requiring submission of clinical information, dosing, diagnosis, lab results (including inhibitor testing), and other documentation to support coverage.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHemophilia Product Prior Authorization Form_Fillable_0918_General

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed form, progress notes, bleeding diaries, and all lab results to 1-844-639-7906 (or call 401-427-8200) to request prior authorization for listed hemophilia products.

SourceLink

POLICY UPDATE CHANGES

No material changes — the prior authorization form and clinical/coverage requirements remain unchanged.

35Listed Products

8Primary Diagnoses

3Severity Categories

Coverage Summary

Overview: This is a fillable prior authorization request form for hemophilia and related coagulation products used to collect administrative and clinical information needed to evaluate coverage requests. Coverage stance: covered_with_criteria. Payer: Neighborhood Health Plan of Rhode Island.

Medical Necessity / Prior Authorization Criteria

General Prior Authorization Requirements

Request will be considered when ALL of the following administrative and clinical documentation elements are provided:

ALL of the following

Administrative and identifying information: Completed prior authorization form with patient, provider, pharmacy, and insurance information
Product and diagnosis: Specify product name (one of the listed hemophilia products) being requested; Provide primary diagnosis (choose from listed diagnoses) and include ICD-10 code
Disease severity and dosing: Provide severity of disease selection: Mild (6%–25%), Moderate (1%–5%), or Severe (<1%); Provide dosing: Dose (IU), Number of Doses Requested, Total Dose Requested (IU), Dosing Instructions
Type and place of use: Provide intended Type of Use (Episodic, Prophylaxis, Acute Bleeding Episode, Dental Procedure date, Surgical Prophylaxis date) and Place of Administration (Home infusion, Outpatient HTC, Outpatient Hospital, Provider's office, Self-administration)
Supporting documentation: Attach relevant progress notes and/or bleeding diaries; All lab results must be faxed in
Diagnosis confirmation and factor level documentation
- Factor level documentation (at least one applicable): Select and provide the applicable factor level(s): Factor VIII for Hemophilia A; Factor IX for Hemophilia B; Factor X for Hereditary Factor X Deficiency; Factor XIII for Congenital Factor XIII or Factor XIII A-subunit Deficiencies; von Willebrand factor for von Willebrand Disease
Inhibitor and ITI information: Indicate whether patient has inhibitors to factor products (Yes/No) and attach documentation of inhibitor tests (e.g., Bethesda assay) if present; If previously received Immune Tolerance Induction (ITI), provide date, duration, and patient response
Minimally treated patients: For minimally treated patients (<50 exposure days) previously on a different product, specify frequency of inhibitor testing

Product-specific / diagnosis-specific additional requirements

Additional clinical questions to be completed when applicable:

Glanzmann's Thrombasthenia-specific: If Glanzmann's Thrombasthenia: indicate whether platelet transfusions were tried and provide date/response

von Willebrand Disease-specific: If von Willebrand Disease: indicate whether desmopressin was tried or is contraindicated; if contraindicated, provide reason

Acute bleeding episode details: For acute bleeding episodes: provide location, type (Minor/Moderate/Major), start and end dates, number of doses used, dose (IU), total amount used (IU)

Treatment history: For treatment-naïve vs treatment-experienced: indicate status and prior product use and reason for switching if applicable; indicate prior ITI therapy (with dates/duration/response)

Inventory / Retrospective Request

Inventory: Provide Patient Inventory: Total Number of Doses on Hand, Total Units on Hand (IU), Date Verified

Retrospective request: Indicate whether request is retrospective (Yes/No); retrospective requests must be clearly marked on the form

Provider Actions / Required Documentation

Prior Authorization

Submit completed PA form and supporting documentation

Fax the completed form, progress notes, bleeding diaries, and all lab results to 1-844-639-7906 (or call 401-427-8200) to request prior authorization for listed hemophilia products.

Fax: 1-844-639-7906
Phone: 401-427-8200

Documentation Required

Attach laboratory confirmation and inhibitor testing

Provide documentation of diagnosis-confirming blood coagulation testing, baseline factor levels (with date), desired target factor level, and inhibitor testing (e.g., Bethesda assay) when applicable.

Documentation Required

Provide prior treatment history and response

Indicate prior factor products, reason for switching, prior ITI therapy (with dates/duration/response), and platelet transfusion/desmopressin trials and contraindications when applicable.

Documentation Required

Inventory and retrospective requests

If retrospective, indicate and provide total doses/units on hand and date verified; retrospective requests must be clearly marked on the form.

Background

Background: This is a fillable prior authorization form used by Neighborhood Health Plan of Rhode Island to collect necessary administrative and clinical information to evaluate coverage requests for hemophilia and related coagulation factor products. The form requests patient, provider, and pharmacy information; specifies the product requested (from a listed set of hemophilia and coagulation products); asks for primary diagnosis and ICD-10 code; documents severity of disease, dosing details, type and place of use, treatment history, bleeding history, inventory and retrospective status; and requires submission of progress notes, bleeding diaries, and all laboratory results (including factor levels and inhibitor testing) via fax to 1-844-639-7906 or by phone at 401-427-8200.

Definitions: Minimally treated patient — < 50 exposure days to factor products.

Feiba
Helixate FS
Alphanate
Hemlibra
Wilate
Feiba NF
Kogenate FS
Humate-P
BeneFIX
Idelvion

OpenPayer

Hemophilia Product Prior Authorization Form_Fillable_0918_General

Coverage Summary

Medical Necessity / Prior Authorization Criteria

Codes and Affected Products

Provider Actions / Required Documentation

Background

Revision History