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It collects patient demographics, insurance details (including Aetna, Medicare, and Medicaid), prescriber and dispensing provider information, product selection and dosing, and diagnosis codes (ICD). The clinical section documents osteoarthritis of the knee status, radiographic support, symptom criteria, age and lab thresholds, and response to prior non-pharmacologic treatment.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/hyaluronates-injectable-medication-precertification-request-page-1-of-2/288460/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/hyaluronates-injectable-medication-precertification-request-page-1-of-2/288460.png","ImageObject",442,249,{"name":88,"@type":89},"วิน","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required to complete the Hyaluronates precertification request form?","Question",{"text":108,"@type":109},"The form requires patient demographics, insurance details, prescriber and dispensing provider information, selected hyaluronate product with dose and frequency, diagnosis ICD codes, and required clinical documentation.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which insurance program details must be provided?",{"text":113,"@type":109},"It requests Aetna member and group identifiers, and asks whether Medicare and Medicaid apply, including ID numbers when applicable.",{"name":115,"@type":106,"acceptedAnswer":116},"What clinical criteria are used to document knee osteoarthritis for the request?",{"text":117,"@type":109},"The form asks whether the patient has knee osteoarthritis and whether diagnosis is supported by radiographic evidence, plus symptom/sign criteria such as specific signs and thresholds, and whether knee pain interferes with functional activities.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288460,1790199136,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},2336475104736,"https://ap-avatar.wpscdn.com/avatar/22000c4c5e0e5b17e70?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786591360781797222","Hyaluronates Injectable Medication Precertification Request Page 1 of 2  \n(All fields must be completed and legible for Precertification Review.)  \nAetna Precertification Notification Phone: 1-866-752-7021 (TTY: 711)  \nFAX:  1-888-267-3277  \nFor Medicare Advantage Part B: Please use Medicare Request Form  \nPlease indicate:  Start of treatment: Start date  / /   Continuation of therapy (Request Additional Series Below) Precertification Requested By:   Phone:   Fax:    \n\n| A. PATIENT INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| First Name: |  |  |  |  |  |  |  | Last Name: |  |  |  |  |  |  |  |  |  |  |  |\n| Address: |  |  |  |  |  |  |  | City: |  |  |  |  |  | State: |  |  |  | ZIP: |  |\n| Home Phone: |  |  |  |  |  | Work Phone: |  |  |  |  |  | Cell Phone: |  |  |  |  |  |  |  |\n| DOB: |  |  |  |  | Allergies: |  |  |  |  |  |  | Email: |  |  |  |  |  |  |  |\n| Current Weight:   lbs or   kgs Height:   inches or   cms |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| B. INSURANCE INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Aetna Member ID \\#:   Group \\#:   Insured:   |  |  |  |  |  |  | Does patient have other coverage?  Yes  No\u003Cbr>If yes, provide ID\\#:   Carrier Name:   Insured:   |  |  |  |  |  |  |  |  |  |  |  |  |\n| Medicare:  Yes  No If yes, provide ID \\#:   Medicaid:  |  |  |  |  |  |  |  |  |  | Yes |  No If yes, provide ID \\#:   |  |  |  |  |  |  |  |  |\n| \u003Cbr>C. PRESCRIBER INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| First Name: |  |  |  |  |  |  | Last Name: (Check One):  |  |  |  |  |  |  |  |  | M. D.  |  |  D.O.  | N. P.  P.A. |\n| Address: |  |  |  |  |  |  |  |  | City: |  |  |  |  | State: |  |  |  | ZIP: |  |\n| Phone: |  |  |  |  | Fax: |  | St Lic \\#: |  | NPI \\#: |  |  |  | DEA \\#: |  |  |  | UPIN: |  |  |\n| Provider Email: |  |  |  |  |  |  | Office Contact Name: |  |  |  |  |  |  |  | Phone: |  |  |  |  |\n| Specialty (Check one):  Orthopedic  Primary Provider  Other:   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Place of Administration:\u003Cbr> Self-administered  Physician’s Office\u003Cbr> Outpatient Infusion Center Phone:  \u003Cbr>Center Name:  \u003Cbr> Home Infusion Center Phone:   Agency Name:  \u003Cbr> Administration code(s) (CPT):   Address:   |  |  |  |  |  |  |  |  | Dispensing Provider/Pharmacy: Patient Selected choice\u003Cbr> Physician’s Office  Retail Pharmacy\u003Cbr> Specialty Pharmacy  Other   Name:   Address:   Phone:   Fax:   TIN:   PIN:   |  |  |  |  |  |  |  |  |  |  |\n| \u003Cbr>E. PRODUCT INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Request is for:  Euflexxa (1% sodium hyaluronate)\u003Cbr> Durolane (hyaluronic acid)\u003Cbr> Gel-One (cross-linked hyaluronate)  Gelsyn-3 (sodium hyaluronate 0.84%)  GenVisc 850 (sodium hyaluronate)  Hyalgan (sodium hyaluronate)\u003Cbr> Hymovis (high molecular weight  Synvisc (hylan G-F 20) viscoelastic hyaluronan)  Synvisc-One (hylan G-F 20)\u003Cbr> Monovisc (high molecular weight hyaluronan)  Triluron (sodium hyaluronate)\u003Cbr> Orthovisc (high molecular weight hyaluronan)  TriVisc (sodium hyaluronate)\u003Cbr> Supartz FX (sodium hyaluronate)  Visco-3 (sodium hyaluronate)\u003Cbr> Synojoynt (1% sodium hyaluronate)  1% sodium hyaluronate\u003Cbr>Dose:   Frequency:   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| F. DIAGNOSIS INFORMATION – Please indicate primary ICD Code and specify any other where applicable. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Primary ICD Code:   Secondary ICD Code:   Other ICD Code:   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| G. CLINICAL INFORMATION – Required clinical information must be completed in its entirety for all precertification requests. |  |  |  |  |  |  |  |  |  |  |","cbCaigwDSZcyAOpk","https://ap.wps.com/l/cbCaigwDSZcyAOpk","pdf",750699,"English","# Patient Information\n# Insurance Information\n# Prescriber Information\n# Dispensing Provider/Administration Information\n# Product Information\n# Diagnosis Information\n# Clinical Information","[{\"question\":\"What information is required to complete the Hyaluronates precertification request form?\",\"answer\":\"The form requires patient demographics, insurance details, prescriber and dispensing provider information, selected hyaluronate product with dose and frequency, diagnosis ICD codes, and required clinical documentation.\"},{\"question\":\"Which insurance program details must be provided?\",\"answer\":\"It requests Aetna member and group identifiers, and asks whether Medicare and Medicaid apply, including ID numbers when applicable.\"},{\"question\":\"What clinical criteria are used to document knee osteoarthritis for the request?\",\"answer\":\"The form asks whether the patient has knee osteoarthritis and whether diagnosis is supported by radiographic evidence, plus symptom/sign criteria such as specific signs and thresholds, and whether knee pain interferes with functional activities.\"}]","Hyaluronates Injectable Medication Precertification Request - Page 1 of 2 | PDF",1789633508]