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MEDICAID PRESCRIPTION DRUG DENIAL: CLIENT INTAKE SCREENING FORM NAME OF CLIENT: _________________________________________________________ DATE OF DENIAL: _________________________________________________________ DATE OF INTAKE: _________________________________________________________ 1. Has client contacted Ombudsman Project and given all required information?
(If “no,” advise client to do so, and provide self-helpletter (Attachment A) 2. If client has contacted Ombudsman’s office and provided all required information, has
client submitted fair hearing request?
(If “no,” advise client how to submit complete andproper request, and to return to legal services/legalaid office if hearing scheduled or if hearing requestreturned as incomplete.) 3. If reason for denial is due to lack of prior authorization, did client contact doctor or
doctor’s office?
(If “no,” advise client to do so, and advise that onlythe doctor or doctor’s staff can request priorauthorization.) MEDICAID PRESCRIPTION DRUG DENIAL: CLIENT INTERVIEW CHECKLIST NOTE: If client has not yet: (1) contacted doctor if reason for denial due to lack of prior authorization, or (2)
contacted Ombudsman Project, and given it three days to resolve problem, or (3) submitted a hearing
request, then give client self-help letter.
NAME OF CLIENT: ____________________________________________________________ DATE OF DENIAL: ____________________ REASON FOR DENIAL: _____________________ Is client in an HMO?
1.1 If “yes,” name of HMO: ____________________________________________ If reason for denial is due to lack of prior authorization (“PA”), did doctor try to get
PA?
If “yes,” what happened?___________________________________________ 2.1.1 If doctor tried and was unable to get PA, can client get statement from doctor or doctor’s staff documenting unsuccessful attempt(s) to receive prior authorization (see attached draft statement)? 2.1.2 _________________________________________________________ (doctor’s name and contact information) If “no,” why? ____________________________________________________ (e.g., did not know number to call; hold time was too long. If doctor did not know whom to call, advise to call the toll-free ombudsman line.) If reason for denial is due to lack of PA, was drug subject to PA?
Does drug exceed 4 brand names in the month? NOTE: If answer to any of the above is “yes,” then reason for denial due to proper authorization is valid,unless exception 3.4, below, applies.
1 The Florida Medicaid Preferred Drug List (updated 4/12/04), can be found at: 2 The list of protocol drugs can be found at: Is drug exempt from prior authorization (e.g. generic, drug used to treat serious mental illness3, antiviral drug used to treat HIV)? Is reason for denial (for a reason other than lack of prior authorization) factually
accurate?
4.1 If “yes,” explain: _________________________________________________ (e.g. reason was “early refill,” even though last refill was over 30 days ago.) Why did the Ombudsman not resolve the problem?
Ombudsman did not respond within 3 business days? Client was unable to contact Ombudsman Project? 5.2.1 If “yes,” why? ____________________________________________ (e.g. no answer, line busy, no translator) Was client denied prescription for a refill (i.e., exact prescription same drug
Medicaid or Medicaid HMO paid for the month before)?
If “yes,” did client get 3-day supply? 6.2 If “no,” did reason for denial indicate: 6.2.3 Drug may cause adverse medical reaction? Has hearing been scheduled?
If “no,” was hearing request returned? 7.2.1 If “no,” does client have valid reason4 for request? 3 See Attachment B, list of drugs used to treat serious mental illness.
4 See Attachment C, Hearing Review Checkli MEDICAID PRESCRIPTION DRUG DENIAL: SELF-HELP LETTER [Insert Program Letterhead]
You requested assistance because your prescription drug was denied coverage, but you had not yet contacted the Ombudsman Project for Medicaid or your Medicaid HMO. You needto give the Ombudsman or your Medicaid HMO three business days to fix your prescription drugproblem. Also, if the reason for denial was “lack of prior authorization,” you need to ask yourdoctor to call for prior authorization. If he or she does not know the number to call, tell them tocall the toll-free Ombudsman number at 1/866-490-1901.
If the Ombudsman is unable to help you, and your doctor has tried to get prior authorization (if that is the reason for denial), you can request a fair hearing. You should fill outthe form on the back of the pamphlet you received at the pharmacy and be sure to follow all thedirections on the pamphlet. Also, be sure to sign the request. If you were denied a refill of the exact prescription you had the month before which
Medicaid or your HMO did pay for, be sure to check Box #2 on the fair hearing request form.
Doing so indicates that you want to keep getting your medication until the hearing officer makes
a decision. You must then fax the hearing request to the Ombudsman and send it to the
address on the form. The Ombudsman fax number is: 1/866-490-1902. Be sure to keep a copy
of the confirmed fax transmission for your records.
Please feel free to re-contact this office if: (1) your fair hearing is scheduled; (2) your request is sent back as incomplete; (3) your prescription was for a refill and you cannot get themedication; or (4) if you have any other questions. I am also giving you a brochure that mayanswer more of your questions.
Attachment A
Drugs Used to Treat Severe Mental Illness Which Should be Exempt
From Prior Authorization

Generic Name
Brand Name
Attachment B
FAIR HEARING REQUEST FORM REVIEW CHECKLIST
1. Has the recipient either filled in the blank indicating the reason(s) the prescription was denied, orattached a computer printout from the pharmacy indicating the denial reason(s)? If “no”, send recipient the Notice of Fair Hearing Request Rejection form, and as reason forrejection of hearing request state: “No reason provided for denial of drug coverage” 2. Has the recipient circled either number 3, number 4, or number 5? If “no”, send recipient the Notice of Fair Hearing Request Rejection form, and as reason forrejection of hearing request state: “Did not indicate appropriate reason for hearing request bycircling either number 3, 4, or 5" 3. Did the recipient circle only number 3? If yes, did the recipient attach any of the following: a) A statement from the prescribing physician or a member of the physician’s staff stating that he or she called or faxed the prior authorization request and was either unable to get throughor provided the requested information; or b) A statement that the drug does not require prior authorization because the reason for rejection received from Medicaid is “drug requires prior authorization because recipient alreadyreceived four brand name drugs this month” and the recipient states that she or he has notreceived four brand name prescriptions this month; or c) A statement that the drug does not require prior authorization because the reason for rejection received from Medicaid is “drug requires prior authorization because not on thepreferred drug list (PDL)”, and the recipient states that the drug is on the PDL or is ageneric; or d) A statement that the drug does not require prior authorization because recipient states that the drug is used to treat mental illness or is an anti-viral drug used to treat H.I.V. If “no”, send recipient the Notice of Fair Hearing Request Rejection form, and as reason forrejection of hearing request state: “Did not attach evidence that your doctor tried to get priorauthorization or that the drug is not subject to prior authorization.” 4. Did recipient or recipient’s authorized representative sign the form in the blank for signature? (Ifsigned by the recipient’s authorized representative, the recipient’s signature is not required.) If “no”, send recipient the Notice of Fair Hearing Request Rejection form, and as reason forrejection of hearing request state: “Did not sign hearing request under penalty of perjury.” Attachment C
F:\Miriam\hernandez implementation\client intake forms.wpd

Source: http://www.floridalegal.org/Health/miriam/client%20intake%20forms.pdf