Behind Every Rx is a Patient.
.
Support: 732.902.6575
ENROLLMENT
|
Rx QUICK REFILL
|
Mobile DELIVERY
ASPRX PORTAL
Login
|
Register
Toggle navigation
Plan Members
Member Enrollment
Member Services
Apogee For
Patients
Payors
Prescribers
Manufacturers
Services
Pharmacy
Nursing
Financial
Infusion & Injection-old
340B
Customized Delivery
Flu Program
About
Who We Are
Careers
Portal
Contact
Home
>
PA
PA
PA
Pending Case Form
All
*
fields are mandatory.
Claimant Information
Claimant First Name
*
Claimant Last Name
*
Insured First Name
Insured Last Name
Policy Number
Social Security Number
Client Information
Client Code
*
Select Code
0000
1111
Client Case Number
Client Service Type
Submitter Name
*
Submitter Email Address
*
Submitter Fax Number
*
Submitter Phone Number
*
Case Details
Funded Type
*
Fully Insured
Partially Insured
Funded Other
Category
*
Medical
Category Other
Review Type
*
Standard (Full Review)
Case Level
*
Initial
Review Case Type
*
Medical Necessity
Review Case Type Other
Review Phase
*
Preservice
Requested Turn Around Time
*
Standard (3-4 business days)
Preferred Specialty 1
*
Preservice
Preferred Specialty 2
*
Preservice
Date of Service
Plan State of issue
Plan State
Require Same State Reviewer
Require Same State Reviewer
Reviewer License State
Reviewer License State
Claimant Address 1
Claimant Address 2
Claimant City
Claimant State
Claimant City
Claimant Zip
Facility Fee
No
Yes
Fee Review
No
Yes
Coding Only By MD
No
Yes
Coding & UC R By MD
No
Yes
UC & R Percentile
Some Value
Instructions
Case Questions
Case Instructions
Case Notes
Case Documentations
Documentation Pages
Documentation Delivery Method
Some Value
SAVE