Clinical trials prior authorization form
A prior authorization form and coverage checklist for determining whether routine patient care costs associated with participation in clinical trials are covered for Priority Health members; specifies eligibility criteria, required documentation, and notes Medicaid exclusion and self-funded group variability.
No material clinical/coverage changes.
Coverage Summary — clinical trials routine patient care costs
This is a prior authorization form to request coverage verification for routine patient care costs associated with participation in clinical trials for Priority Health. Note that Clinical trials aren't covered for Priority Health Medicaid, and coverage for members in self-funded groups must be verified with the individual plan document. The form collects required sections including member information, provider information, facility information, clinical trial details (diagnosis/procedure codes, trial protocol, sponsor/funding, NCT/clinical trial number), and supporting documentation (e.g., CMS/NGS approval, informed consent, advance care planning if applicable).
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