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Prior Authorization worksheet - Office of Mental Health - New York ...

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NEW YORK STATE MEDICAID PROGRAM<br />

RISPERDAL CONSTA<br />

PRIOR AUTHORIZATION WORKSHEET<br />

PRESCRIBER IDENTIFIER<br />

NYS Physician License<br />

NYS Nurse Practitioner License<br />

OR<br />

Out-<strong>of</strong>-State Prescriber License<br />

Client Identification Number<br />

Physician Telephone Number with Area Code<br />

Complete one <strong>of</strong> the following prescriber identifiers:<br />

0 0 __ __ __ __ __ __<br />

F __ __ __ __ __ __<br />

OR<br />

__ __ __ __ __ __ __ __<br />

(Use the first two spaces for the alpha letters representing the<br />

state the prescriber’s license originates from.)<br />

__ __ __ __ __ __ __ __<br />

__ __ __ - __ __ __ - __ __ __ __<br />

Risperdal Consta J-code J 2 7 9 4<br />

DOSE Press 1 for 25mg injection (50 units)<br />

Press 2 for 37.5mg injection (75 units)<br />

___<br />

Press 3 for 50mg injection (100 units)<br />

Press 4 for 12.5mg injection (25 units)<br />

Total Number <strong>of</strong> Doses (Initial <strong>Authorization</strong>s or order requesting a Change in<br />

Dose cannot exceed 6 doses; Re-authorizations cannot exceed 13 doses ) ___ ___<br />

1 dose = single dose; 2 doses = 1 month; 13 doses = 6 months<br />

PRIOR AUTHORIZATION JUSTIFICATION INFORMATION<br />

1. Does the patient have a diagnosis <strong>of</strong> schizophrenia or schizoaffective disorder? Yes ___ No___<br />

2. Can the patient tolerate a minimum <strong>of</strong> 2 mg/day <strong>of</strong> oral risperidone? Yes___ No___<br />

3. To the best <strong>of</strong> your knowledge, are you the only prescriber <strong>of</strong> antipsychotic medications for Yes___ No___<br />

this patient?<br />

4. Is the patient 18 years <strong>of</strong> age or older? Yes___ No___<br />

5. Has the patient been tried on regimens <strong>of</strong> oral antipsychotics and found to be poorly<br />

Yes___ No___<br />

adherent?<br />

If your patient is currently on Risperdal Consta press 1 now. If this Risperdal Consta<br />

order represents a new therapy for your patient press 2 now.<br />

(Questions 6, 7, & 8 are for patients currently receiving Risperdal Consta.)<br />

6. Has the patient been on other antipsychotic drugs for longer than 60 days since treatment<br />

with Risperdal Consta began?<br />

Yes___ No___<br />

7. For patients on Risperdal Consta, is the patient compliant with current therapy? Yes___ No___<br />

8. For re-authorization, has the patient shown measurable improvement in target symptoms<br />

since Risperdal Consta therapy was initiated?<br />

Yes___ No___<br />

BILLING PROVIDER (OMH Approved Facility MMIS Number OR Physician /Nurse Practitioner<br />

or Group Practice MMIS Number )<br />

CATEGORY OF SERVICE<br />

(COS = 0163) OMH Approved Free Standing <strong>Mental</strong> <strong>Health</strong> Clinic/CDT/P.H.<br />

(COS = 0282) OMH Approved Hospital Based Clinic/CDT/P.H.<br />

(COS = 0163) OMH Approved ACT Providers<br />

(COS-= 0460) Physician Private Practice<br />

(COS = 0469) Nurse Practitioner Private Practice<br />

__ __ __ __ __ __ __ __<br />

__ __ __ __<br />

PRIOR AUTHORIZATION NUMBER<br />

Record the eleven digit prior authorization number here for your records and<br />

on the top <strong>of</strong> the patient’s medical record. Retain Worksheet.<br />

__ __ __ __ __ __ __ __ __ __ __<br />

PRESCRIBER SIGNATURE AND DATE<br />

x____________________________________________________________________ DATE: ___/___/___<br />

For billing questions, contact 1-800-343-9000.<br />

For clinical concerns contact OMH at 518-474-6911


NEW YORK STATE MEDICAID PROGRAM<br />

RISPERDAL CONSTA<br />

PRIOR AUTHORIZATION WORKSHEET<br />

Procedure:<br />

♦ Prescriber writes order for Risperdal Consta (J2794) with dosage strength indicated in medical record.<br />

♦ Prescriber or agent calls 1-800-778-6052<br />

♦ Information can be entered either by voice or by using the phone keypad.<br />

PRESCRIBER IDENTIFIER: Choose Prescriber Option and enter the LICENSE number. DO NOT submit MMIS.<br />

• Choose '1' for Physician (Residents/physician assistants must use the license number <strong>of</strong> their supervising physician.)<br />

• Choose ‘2’ for Nurse Practitioner<br />

• Out <strong>of</strong> State prescribers will be prompted to give the alpha designation for their state (e.g. Vermont is VT) and then, the last six<br />

numbers <strong>of</strong> that state license.<br />

CLIENT IDENTIFICATION NUMBER: Enter the patient's Medicaid client identification number (2 letters, 5 numbers, 1 letter).<br />

Follow the prompts.<br />

PRESCRIBER TELEPHONE NUMBER: Enter your ten-digit telephone number (area code/number).<br />

PRODUCT VERIFICATION: You will be asked to verify that your are calling about Risperdal Consta (J-code J2794)<br />

DOSAGE: Enter the dosage selection:<br />

Press 1 for 25mg injection (50 units)<br />

Press 2 for 37.5mg injection (75 units)<br />

Press 3 for 50mg injection (100 units)<br />

Press 4 for 12.5mg injection (25 units)<br />

DOSES: Enter Total Number <strong>of</strong> Doses (Initial <strong>Authorization</strong>s or order requesting a change in dose cannot exceed 6 doses;<br />

Re-authorizations cannot exceed 13 doses) e. g. 1 dose = single dose; 2 doses = 1 month; 13 doses = 6 months<br />

PRIOR AUTHORIZATION JUSTIFICATION INFORMATION:<br />

Respond "Yes" or "No" to the following questions:<br />

1. Does the patient have a diagnosis <strong>of</strong> schizophrenia or schizoaffective disorder?<br />

2. Can the patient tolerate a minimum <strong>of</strong> 2 mg/day <strong>of</strong> oral risperidone?<br />

3. To the best <strong>of</strong> your knowledge, are you the only prescriber <strong>of</strong> antipsychotic medications for this patient?<br />

4. Is the patient 18 years <strong>of</strong> age or older?<br />

5. Has the patient been tried on regimens <strong>of</strong> oral antipsychotics and found to be poorly adherent?<br />

If your patient is currently on Risperdal Consta press 1 now. If this Risperdal Consta order represents a new therapy for<br />

your patient press 2 now.<br />

(Questions 6, 7, & 8 are for patients currently receiving Risperdal Consta.)<br />

6. Has the patient been on other antipsychotic drugs for longer than 60 days since treatment with Risperdal Consta began?<br />

7. For patients on Risperdal Consta, is the patient compliant with current therapy?<br />

8. For re-authorization, has the patient shown measurable improvement in target symptoms since Risperdal Consta therapy<br />

was initiated?<br />

BILLING PROVIDER MMIS NUMBER: Enter the MMIS number <strong>of</strong> the OMH approved facility. If prescriber is treating patient<br />

privately, use the MMIS number <strong>of</strong> the billing private or group practice. (8 value number used for Medicaid billing)<br />

CATEGORY OF SERVICE: Enter the appropriate Category <strong>of</strong> Service for the OMH approved facility or private practice billing<br />

entity.<br />

COS = 0163 OMH Approved Free Standing <strong>Mental</strong> <strong>Health</strong> Clinic/CDT/P.H.<br />

COS = 0282 OMH Approved Hospital Based Clinic/CDT/P.H.<br />

COS = 0163 OMH Approved ACT Providers<br />

COS-= 0460 Physician Private Practice<br />

COS = 0469 Nurse Practitioner Private Practice<br />

♦ A prior authorization number will be returned; write it legibly on the <strong>worksheet</strong> and patients medical record.<br />

♦ This prior authorization number must be included on all submitted claims. It will be used for billing/payment guidelines.<br />

♦ <strong>Prior</strong> authorization does not guarantee payment. Payment is subject to patient eligibility and other Medicaid guidelines.<br />

♦ If a dosage change is necessary, a new prior authorization must be requested.<br />

♦ Do not fax a copy <strong>of</strong> this <strong>worksheet</strong>, it must be kept in the patient's medical chart for future reference.<br />

♦ The Risperdal Consta <strong>Prior</strong> <strong>Authorization</strong> Worksheet should be reproduced for future prescribing.<br />

For billing questions, contact 1-800-343-9000.<br />

For clinical concerns contact OMH at 518-474-6911

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