[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-286812-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-286812-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","medicare-outpatient-medical-part-b-drug-authorization-request-form-new-jersey","Medicare Outpatient Medical Part B Drug Authorization Request Form - New Jersey","","This form is the official New Jersey Medicare Outpatient Medical Part B Drug Authorization Request document for the year 2025. It is designed for healthcare providers to request authorization for Part B drugs by providing essential member information, requesting provider details, and servicing provider or facility information. The document requires specific clinical procedure codes, ICD-10 diagnosis codes, and units of service. Comprehensive clinical documentation is mandatory to ensure timely processing and avoid rejection. 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Members must be eligible at the time services are rendered, and services must be medically necessary and a covered benefit under the Plan.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},286812,1789631574,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":33,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":79,"read_time":4},1099514067415,"https://ap-avatar.wpscdn.com/avatar/100002539d78ffe74a7?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779092875211072502","MEDICARE OUTPATIENT MEDICAL PART B  \nDRUG AUTHORIZATION REQUEST FORM  \nNEW JERSEY  \nAll Part B Drug Requests: Fax 844-235-5090  \n Urgent Requests  \n* INDICATES REQUIRED FIELD    \nDate of Birth*  \nMEMBER INFORMATION   \nMember ID* Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \n*  \nRequesting NPI  \nRequesting Provider Name  \n*  \nRequesting TIN  \nPhone  \nRequesting Provider Contact Name  \nFax*  \nSERVICING PROVIDER / FACILITY INFORMATION  \n Same as Requesting Provider  \nServicing NPI*  \nServicing Provider/Facility Name  \nServicing TIN*  \nPhone  \nServicing Provider Contact Name  \nFax  \nAUTHORIZATION REQUEST  \nPrimary Procedure Code*  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \n*  \nPrimary Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code End Date OR Discharge Date  \n(CPT/HCPCS) (Modifier) (MMDDYYYY)  \nDiagnosis Code*  \n(ICD-10)  \nTotal Units/Visits/Days  \nTotal Units/Visits/Days  \nTotal Units/Visits/Days  \nTotal Units/Visits/Days  \nALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.  \nCOPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.  \nDisclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policy and procedures.  \nConfidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the  \nintended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document. Rev. 07 08 2025","cbCaitGKEFFfh7Ut","https://ap.wps.com/l/cbCaitGKEFFfh7Ut","pdf",1053359,"English","# Member and Provider Information\n## Requesting Provider Details\n## Servicing Provider/Facility Information\n# Authorization Request\n## Procedure and Diagnosis Details\n## Clinical Submission Requirements","[{\"question\":\"Where should completed Part B drug authorization requests be faxed?\",\"answer\":\"All Part B drug requests should be faxed to 844-235-5090.\"},{\"question\":\"What documentation must accompany this form?\",\"answer\":\"Copies of all supporting clinical information are required for the authorization request; failure to provide this may result in a delayed determination.\"},{\"question\":\"Does an approved authorization guarantee payment?\",\"answer\":\"No, an authorization is not a guarantee of payment. Members must be eligible at the time services are rendered, and services must be medically necessary and a covered benefit under the Plan.\"}]","Medicare Outpatient Medical Part B Drug Authorization Request Form - New Jersey | PDF"]