INTRA ARTICULAR HYALURONAN INJECTIONS ... - Blue …

1 For Blue Cross NC members, fax form to 1-800-795-9403 For NC State Health Plan members (Member ID YPY), fax form to 1-866-225-5258 Last Revision Date: January 2019 INTRA ARTICULAR HYALURONAN INJECTIONS PRIOR REVIEW/CERTIFICATION FAXBACK FORM INCOMPLETE FORMS MAY DELAY PROCESSING ALL NC PROVIDERS MUST PROVIDE THEIR 5-DIGIT Blue Cross NC PROVIDER ID# BELOW PRESCRIBER NAME PRESCRIBER NPI [REQUIRED] Blue Cross NC PROV ID # / TAX ID [out of state only] CONTACT PERSON PRESCRIBER PHONE PRESCRIBER FAX PRESCRIBER ADDRESS CITY STATE ZIP PATIENT NAME Blue Cross NC ID DATE OF BIRTH GENDER M F Please answer

2 The following questions for initial treatment (see page 2 for continued treatment): Diagnosis Code:_____ 1. Please check the medication being requested: Preferred products: Durolane (C9465) Gelsyn-3 (J7328) Synvisc / Synvisc One (J7325) Nonpreferred products: Gel-One (J7326) GenVisc (J7320) Euflexxa (J7323) Hyalgan (J7321) Hymovis (J7322) Monovisc (J7327) Orthovisc (J7324) Supartz FX (J7321) Visco-3 (J7321) a.

3 If the request is for a nonpreferred product, has the patient tried and failed or do they have a contraindication/intolerance to Synvisc/Synvisc One AND either Durolane or Gelsyn-3?.. Yes No 2. Please check where the injection (s) will be given: Left knee Right knee Both knees Other: _____ 3. Is the patient scheduled for a total knee replacement within 6 months of starting therapy?.. Yes No 4. Will the requested medication be used to treat osteoarthritis of the knee? .. Yes No 5. Has the patient tried or is unable to utilize exercise, analgesics, NSAIDs, and either physical therapy or weight loss, for at least 3 months without functional improvement?

4 Yes No 6. Is there radiograhical evidence of joint space narrowing, subchondral sclerosis, osteophytes, and sub-chondral cysts?.. Yes No a. If no to 6, is the patient experiencing knee pain, AND does the patient have at least five of the following symptoms: crepitus; erythrocyte sedimentation rate less than 40 mm/hr; less than 30 minutes of morning stiffness tenderness; no palpable warmth of synovium; over 50 years of age; rheumatoid factor less than 1:40 titer; synovial fluid signs; bony tenderness; bony enlargement? Yes No Please certify the following by signing and dating below: I certify that I have been authorized to request prior review and certification for the above requested service(s).

5 I further certify that my patient s medical records accurately reflect the information provided. I understand that Blue Cross NC may request medical records for this patient at any time in order to verify this information. I further understand that if Blue Cross NC determines this information is not reflected in my patient s medical records, BCBSNC may request a refund of any payments made and/or pursue any other remedies available. Prescriber s Signature (Required):_____Date:_____ For Blue Cross NC members, fax form to 1-800-795-9403 For NC State Health Plan members (Member ID YPY), fax form to 1-866-225-5258 Last Revision Date: January 2019 COMPLETE THIS PAGE IF REQUESTING CONTINUED TREATMENT OF AN INTRA ARTICULAR HYALURONAN injection PRESCRIBER NAME PRESCRIBER NPI [REQUIRED] Blue Cross NC PROV ID # / TAX ID [out of state only]

6 CONTACT PERSON PRESCRIBER PHONE PRESCRIBER FAX PRESCRIBER ADDRESS CITY STATE ZIP PATIENT NAME Blue Cross NC ID DATE OF BIRTH GENDER M F Please answer the following questions for continued treatment (see page 1 for initial treatment): Diagnosis Code:_____ 1.

7 Please check the medication being requested: Preferred products: Durolane (C9465) Gelsyn-3 (J7328) Synvisc / Synvisc One (J7325) Nonpreferred products: Gel-One (J7326) GenVisc (J7320) Euflexxa (J7323) Hyalgan (J7321) Hymovis (J7322) Monovisc (J7327) Orthovisc (J7324) Supartz FX (J7321) Visco-3 (J7321) a. If the request is for a nonpreferred product, has the patient tried and failed or do they have a contraindication/intolerance to Synvisc/Synvisc One AND either Durolane or Gelsyn-3?

8 Yes No 2. Please check where the injection (s) will be given: Left knee Right knee Both knees Other: _____ 3. Was the patient previously approved by Blue Cross NC for treatment with an INTRA - ARTICULAR HYALURONAN injection ? .. Yes No If no, please answer all questions on page 1 4. Did the previous treatment result in decreased use of analgesics / anti-inflammatory medications, and significant improvement in pain and functional capacity? .. Yes No 5. Have six months lapsed since the completion of prior treatment? .. Yes No If yes, please answer all questions on page 1 Please certify the following by signing and dating below: I certify that I have been authorized to request prior review and certification for the above requested service(s).

9 I further certify that my patient s medical records accurately reflect the information provided. I understand that Blue Cross NC may request medical records for this patient at any time in order to verify this information. I further understand that if Blue Cross NC determines this information is not reflected in my patient s medical records, BCBSNC may request a refund of any payments made and/or pursue any other remedies available. Prescriber s Signature (Required):_____Date:_____ For Blue Cross NC members, fax form to 1-800-795-9403 For NC State Health Plan members (Member ID YPY), fax form to 1-866-225-5258 Last Revision Date: January 2019 Non-Discrimination and Accessibility Notice Discrimination is Against the Law Blue Cross and Blue Shield of North Carolina ( Blue Cross NC ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

10 Blue Cross NC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross NC: Provides free aids and services to people with disabilities to communicate effectively with us, such as: - Qualified interpreters - Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: - Qualified interpreters - Information written in other languages If you need these services, contact Customer Service 1-888-206-4697, TTY and TDD, call 1-800-442-7028. If you believe that Blue Cross NC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Blue Cross NC, PO Box 2291, Durham, NC 27702, Attention: Civil Rights Coordinator- Privacy, Ethics & Corporate Policy Office, Telephone 919-765-1663, Fax 919-287-5613, TTY 1-888-291-1783 You can file a grievance in person or by mail, fax, or email.