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Helpful Tools When Requesting GHPP Benefits

The information below will assist providers in avoiding denials for specific GHPP services.

Blood Factor

Controlled Substances

Hospitalization/Inpatient Admission

Medical Foods

Enteral Nutrition Products

Power Wheelchair/Scooter

All Types of Lifts (such as a Hoyer lift)

High Frequency Chest Compression Device (The Vest System, ThAirapy Vest)

Home Oxygen Delivery System

Initial Authorization of Dornase Alfa (Pulmozyme)

 

 

Blood Factor

The GHPP requires prior authorization for all factor therapy services. Requests for blood factor must be submitted with a valid written prescription. 

  1. Prescription must be legible and NDC numbers written clearly and correctly.
  2. Prescription must include number of units per dose, frequency of administration, date prescription was written, signature and printed name of prescriber, patient name and date of birth.
  3. Pharmacy providers must include the following information on the SAR form: HCPCS code or NDC number, units per vial and number of vials needed to meet prescribed dose and frequency of use to include + or – 10 percent to accommodate pharmacy’s available factor assay. The request must not exceed 10% of the total units requested.
  4. Prescription must be written by a GHPP approved SCC hematologist or his/her designee.
  5. Request for authorizations should be submitted in a timely manner, preferably five business days prior to the dispense date. Requests for reauthorizations should be submitted at least 2 weeks prior to the expiration of an existing authorization.  
  6. If there is a need for more factor due to a bleed and the amount of factor exceeds the current prescription, the provider must submit a new request with an updated prescription from the SCC physician.
  7. Most important: Obtain prior authorization. Factor dispensed without an authorization may be denied.

For more information regarding factor authorization, please read the Blood Factor Authorization Request Procedure. 

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Controlled Substances

  1. Prescriptions must be written on a controlled substance prescription form, signed and dated by the prescriber in ink.
  2. Request for controlled substances must be clear and legible. 

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Hospitalization/Inpatient Admission 

Submit a SAR form with the following documentation:

  1. Admission face sheet within two business days after admission.  
  2. Copy of the weekly progress report or the discharge summary with request for extension of authorization.

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Medical Foods

 

Submit a SAR with the following documentation: 

  1. Prescription written by a GHPP approved SCC physician
  2. Special Care Center Registered Dietitian (RD) assessment done within the last 6 months
  3. MD assessment or clinical reports done within one year
  4. List and pricing of medical foods being requested

Large Neutral Amino Acids can be a clinical treatment option reimbursed by the GHPP when medical foods are not fully treating a metabolic condition.  If you have any questions, please call the GHPP.

Criteria for the approval of Large Neutral Amino Acids (LNAA’s):

  1. Prescription written by a GHPP approved SCC physician
  2. Medical reports that indicate a diagnosis of PKU currently treated or never been treated, non-compliance with a PHE restricted diet, and clinical complications, specifically psychiatric manifestations
  3. Laboratory test results that show significantly elevated serum PHE levels (consistently elevated beyond 15 mg/dl) 

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Enteral Nutrition Products

Submit a SAR with the following documentation: 

  1. Prescription written by a GHPP approved SCC physician
  2. Special Care Center RD assessment done within the last 6 months

Completed GHPP request for enteral nutrition product form (link to the new form)

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Power Wheelchair/Scooter

Submit a SAR with the following documentation:

  1. Prescription written by a GHPP approved SCC physician (must be within six months)
  2. Physician’s medical report with current physical examinations
  3. Statement of medical necessity
  4. Completed service authorization request form or specification sheet/cost estimate
  5. Catalog pages and pricing information
  6. Physical Therapy or Occupational Therapy report
  7. If the request is for replacement of an existing DME, include documentation on the status of the current DME

 

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All Types of Lifts (such as a Hoyer lift)

Submit a SAR with the following documentation:

  1. Prescription written by a GHPP approved SCC physician
  2. Statement of provider’s agreement to rent or loan DME for up to three months prior to purchase
  3. Home assessment report that includes the size of the rooms and doorways where the lift will be used
  4. Documentation that client/caregiver is committed to use and has demonstrated safe, functional use of the lift

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High Frequency Chest Compression Device (The Vest System, ThAirapy Vest)

Submit a SAR with the following documentation:

A. Initial authorization:

  1. Statement of  medical necessity signed by a GHPP approved Special Care Center pulmonologist
  2. Documentation showing that other means of mucous clearing device/method have been used and not achieving results
  3. Documentation showing that the client is able to use the high frequency chest compression device independently
  4. Documentation showing that the client has no caregiver able to provide manual Chest Physiotherapy (CPT)
  5. Documentation showing that manual CPT is contraindicated due to client’s underlying condition such as GERD.

B. Re-Authorization:

  1. Prescription signed by the Special Care Center pulmonologist
  2. Documentation of patient compliance to prescribed therapy as shown buy an adherence synopsis printout covering the last three months period

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Home Oxygen Delivery System

Submit a SAR for initial and re-authorization with the following documentation:

  1. Prescription written by a GHPP approved SCC physician that includes the specific type of oxygen delivery system, duration, and liters per minute (LPM). Example: oxygen concentrator at 3 LPM x 12 months. Prescriptions for oxygen written as “PRN” and “use for lifetime” are not acceptable
  2. Results of recent oxygen saturation studies or arterial blood gas
  3. Statement of medical necessity or most recent clinical reports that shows medical justification for use of oxygen therapy.

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Initial Authorization of Dornase Alfa (Pulmozyme) 

  1. Prescription written by a GHPP approved SCC physician
  2. Medical report that indicates client is routinely performing airway clearance techniques
  3. Pulmonary function test result that shows Forced Vital Capacity (FVC) is greater than 40%
  4. Documentation of two or more courses of IV antibiotics in the past 12 months or an ongoing requirement for supplemental oxygen

 

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Last modified on: 4/17/2008 8:08 AM