№ files_lp_3_process_7_063454
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Character count: 2134
File size: 45 KB
Formal prior authorization request letter addressed to a medical director seeking coverage approval for intravenous Infliximab treatment and outlining the required clinical justification and supporting documentation.
Document Type:
Prior Authorization Request Letter
Subject:
Authorization for intravenous Infliximab treatment
Medication:
Infliximab
Request Type:
Standard or Expedited
Addressee:
Medical Director or Prior Authorization Reviewer
Author:
Healthcare Provider
Related Information:
Diagnosis, ICD Code, Dose and Frequency
Supporting Documentation:
Prescribing Information, Peer-Reviewed Articles, Clinical Guidelines
Purpose:
Coverage and Reimbursement Approval
Clinical Content:
Patient Diagnosis, Treatment History, Prognosis, Rationale for Treatment
Site of Service:
Inpatient or Outpatient Medical Facility
Price: 8 / 10 USD
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The product description is provided for reference. Actual content and formatting may differ slightly.
Year:
Not specified
Region / City:
Not specified
Topic:
Infliximab dose escalation in Crohn’s disease treatment
Document type:
Medical request letter
Institution / Organization:
Not specified
Author:
Not specified
Target audience:
Insurance company
Period of validity:
Not specified
Approval date:
Not specified
Date of modifications:
Not specified
Year:
2021
Region / City:
Australia
Topic:
Pharmaceutical Submission
Document Type:
Regulatory Submission
Agency / Institution:
PBAC
Author:
CELLTRION HEALTHCARE AUSTRALIA PTY LTD
Target Audience:
Healthcare professionals, regulatory authorities
Effective Period:
2021 and ongoing
Approval Date:
25 August 2021
Date of Changes:
March 2022
Year:
2022
Region / city:
Australia
Theme:
Rheumatoid Arthritis, Pharmaceutical submission
Document type:
Submission for PBS listing
Organization / institution:
Celltrion Healthcare Australia Pty Ltd
Author:
Celltrion Healthcare Australia Pty Ltd
Target audience:
Health professionals, regulators
Period of validity:
Not specified
Approval date:
Not specified
Date of changes:
Not specified
Year:
2020
Region / City:
Naas, Ireland
Topic:
Healthcare, Medical Protocol
Document Type:
Protocol
Organization:
Naas General Hospital
Author:
Joanna Rea
Target Audience:
Gastroenterology team, Clinical Nurse Manager, Nursing staff, IBD Clinical Nurse Specialist
Period of Validity:
January 2023
Approval Date:
14th of January 2020
Date of Revision:
January 2023
Date of Update:
Not specified
Keywords:
Infliximab, infusion, protocol, healthcare, patient safety, staff training, adverse events, gastroenterology
Year:
2015
Region / city:
Australia
Subject:
Pharmaceutical Submissions, Biosimilars
Document Type:
Application for PBS Listing
Organization / Institution:
PBAC (Pharmaceutical Benefits Advisory Committee)
Author:
Hospira
Target Audience:
Healthcare professionals, regulatory authorities, pharmaceutical industry
Period of validity:
Ongoing
Approval Date:
N/A
Date of changes:
N/A
Year:
2022
Region / City:
USA
Topic:
Kawasaki Disease Treatment
Document Type:
Research Article
Organization / Institution:
Multiple Medical Centers
Author:
Kaitlyn Krebushevski
Target Audience:
Pediatricians, Researchers
Period of Action:
Ongoing
Approval Date:
January 2022
Modification Date:
Not specified
Methodology:
Literature Review, Meta-Analysis, Randomized Control Trials
Year:
2026
Region / City:
United States
Topic:
Federal procurement and contract management
Document Type:
Policy/Guidance
Agency / Institution:
GSA (General Services Administration)
Author:
GSA
Target Audience:
Contractors, Government Agencies
Period of Validity:
Ongoing
Approval Date:
N/A
Modification Date:
N/A
Year:
2026
Region / City:
N/A
Subject:
Prior authorization requirements for lower extremity endovascular procedures
Document type:
Checklist
Organization:
N/A
Author:
N/A
Target audience:
Healthcare providers
Period of validity:
N/A
Approval date:
N/A
Date of amendments:
N/A
Year:
2023
Region / City:
United Kingdom
Topic:
Accreditation of Prior Learning
Document Type:
Standard Operating Procedure
Institution:
Quality Assurance
Author:
Nicola Bell
Target Audience:
Academic staff, students
Period of Validity:
Until September 2025
Approval Date:
04/09/2023
Review Date:
September 2025
Date of Changes:
04/09/2023
Year:
Not specified
Region / City:
Not specified
Topic:
Prior Authorization Request
Document Type:
Letter
Organization / Institution:
Kyowa Kirin Inc.
Author:
Not specified
Target Audience:
Medical professionals, insurance providers
Period of Effectiveness:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
Year:
2023
Region / City:
New York State
Theme:
Cultural Resource Management
Document Type:
Template for Historic Preservation Finding Document
Agency / Institution:
New York State Department of Transportation (NYSDOT)
Author:
Not specified
Target Audience:
Project managers, cultural resource coordinators, historical preservation professionals
Period of Validity:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
Year:
2025
Topic:
Free, Prior and Informed Consent (FPIC)
Document type:
Protocol
Organization / institution:
Blue Action Fund
Author:
Blue Action Fund
Target audience:
NGOs, project developers, indigenous peoples, local communities
Period of validity:
Not specified
Approval date:
Not specified
Date of modifications:
Not specified
Organization:
Driscoll Health Plan
Document type:
Clinical policy and administrative guidelines
Revision date:
November 1, 2024
Geographic scope:
Texas
Programs referenced:
STAR, STAR Kids, CHIP
Subject area:
Therapy services prior authorization and medical necessity
Target audience:
Therapy providers and referring physicians
Authorization method:
Provider web portal and fax submission
Related forms:
Texas Standard Prior Authorization Request Form for Health Care Services (TARF), Therapy Referral Review by Ordering Physician Attestation Form
Effective policy elements:
Initial evaluations, re-evaluations, continuation of therapy, start of care rules
Coverage criteria:
Medical necessity based on clinical documentation
Source type:
Health plan policy guideline
Year:
2023
Region/City:
Illinois
Topic:
Youth support services, Therapeutic support services, Prior authorization process
Document Type:
Form
Organization:
Illinois Department of Healthcare and Family Services (HFS)
Author:
Unknown
Target Audience:
Providers of therapeutic and individual support services
Period of Action:
N/A
Approval Date:
N/A
Amendment Date:
N/A
Year:
Not specified
Region / jurisdiction:
South Carolina
Program:
Medicaid
Document type:
Administrative form
Purpose:
Prior authorization review for inpatient services
Submitting method:
Fax
Fax number:
1-855-300-0082
Responsible organizations:
KePRO; South Carolina Department of Health and Human Services
Provider identification:
National Provider Identifier (NPI); Medicaid ID
Mandatory provider location data:
9-digit ZIP code
Review types:
Initial; Recertification; Change; Cancel; Retrospective review
Service setting:
Inpatient; freestanding inpatient psychiatric
Population focus:
Medicaid members; psychiatric services for children under 21 and adults 65 and older
Eligibility window:
Up to 30 days prior to scheduled services
Clinical information required:
Diagnosis; severity of illness; intensity of services
Approval process:
Subject to medical necessity and eligibility verification
Year:
Not specified
Region / City:
Not specified
Theme:
Education, Articulation Agreements
Document Type:
Protocol
Organization / Institution:
University of Kent
Author:
Not specified
Target Audience:
Higher Education institutions, Admissions Officers, Boards of Studies
Effective Period:
Not specified
Approval Date:
Not specified
Amendment Date:
Not specified
Note:
Contextual Description
Year:
2022
Region / City:
United States
Topic:
Medical necessity, prior authorization, spinal cord stimulation
Document Type:
Template letter
Organization / Institution:
Abbott
Author:
Not specified
Target Audience:
Healthcare providers, insurance companies
Period of validity:
Not specified
Approval date:
Not specified
Amendment date:
Not specified
Year:
Not specified
Region / City:
Not specified
Theme:
Mental health services, youth support
Document Type:
Form
Organization / Institution:
Optum
Author:
Not specified
Target Audience:
Health professionals, social workers, mental health providers
Effective Period:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
Year:
FY19
Region / City:
Massachusetts
Subject:
Higher Education, Program Proposal
Document Type:
Template
Institution / Organization:
Massachusetts Department of Higher Education
Author:
Massachusetts Department of Higher Education
Target Audience:
Higher education institutions, academic administrators
Effective Period:
Ongoing
Approval Date:
Not specified
Modification Date:
Not specified
Context:
This document is a template for the letter of intent required by institutions proposing new academic programs to be submitted for review and approval by the Massachusetts Board of Higher Education.