The ArchimedesRx prior authorization form is the cover sheet your provider submits, along with clinical documentation, to request insurance approval for a specialty medication managed by ArchimedesRx. Most denials come from missing fields or thin clinical backup rather than a real medical disagreement, so filling the form out carefully the first time is the single biggest thing you can do to avoid delays.
Use the Version That Matches Your Plan
ArchimedesRx does not use one universal form. Its resources page hosts a general prior authorization form along with plan-specific versions for several insurers, including Luminare Health, DMBA, Denver Health, Centivo, and Wellstar Health Plan.1ArchimedesRx. Resources If your health plan has its own version, use that one. Submitting the wrong form can trigger a rejection before anyone looks at the clinical details. When you aren’t sure, call the member services number on the back of your insurance card or contact ArchimedesRx directly using the number on your plan documents.
Patient and Insurance Information
The top of the form matches the request to your insurance record. Enter the patient’s first and last name, date of birth, home address, and telephone number exactly as they appear on the insurance card. Even small discrepancies can cause automated rejections before a clinician ever reads the request.2Archimedes, LLC. ArchimedesRx Prior Authorization Form
Then enter the Member ID and Group Number from the card. The Member ID is the primary lookup in the insurer’s system, and the Group Number identifies the employer or plan sponsor. If either is missing, the review team has to track it down manually, which adds days.2Archimedes, LLC. ArchimedesRx Prior Authorization Form
Prescriber Information
The prescriber section asks for the physician’s name, specialty, clinic name and address, phone number, and secure fax number. Two fields cause more trouble than the rest: the National Provider Identifier (NPI) and the direct contact name.2Archimedes, LLC. ArchimedesRx Prior Authorization Form
The NPI is a ten-digit number assigned to every covered healthcare provider under HIPAA and used as the provider’s unique identifier across insurance transactions.3Centers for Medicare & Medicaid Services. National Provider Identifier Standard If your provider doesn’t know theirs offhand, it can be looked up for free on the CMS NPI registry at npiregistry.cms.hhs.gov.
The direct contact name should be a specific person in the provider’s office, such as a nurse, medical assistant, or prior authorization coordinator, who can answer clinical questions if a reviewer calls back. A generic office number with no named contact slows things down, especially when the reviewer needs one clarifying detail to approve the request.
Medication Request
The medication section is where the clinical specifics go. You need all of the following:2Archimedes, LLC. ArchimedesRx Prior Authorization Form
- Medication name, brand or generic, exactly as prescribed.
- Strength, such as 150 mg.
- Dosing schedule, meaning how often the patient takes or receives it.
- Quantity per month for a one-month supply.
- Route of administration: oral, subcutaneous, intravenous, or other.
- Expected length of therapy.
The form also asks whether the medication will be supplied through buy-and-bill or through a specialty pharmacy. Under buy-and-bill, the provider’s office purchases the drug, stores it, administers it, and bills the insurer for reimbursement. Under specialty pharmacy, an outside pharmacy ships the medication to the provider’s office or directly to the patient and handles the drug claim. Check with your provider’s office about which they use, because the wrong choice here creates billing problems after the authorization is granted.
Clinical Documentation To Attach
The form itself is a cover sheet. The clinical documentation you attach is what actually drives the decision. Reviewers are looking for a clear story: the patient has a confirmed diagnosis, the requested drug fits that diagnosis, and cheaper alternatives have been tried or genuinely don’t apply.
Diagnosis and ICD-10 Codes
Every request needs the patient’s diagnosis as an ICD-10 code. ICD-10 is the standardized coding system used across the U.S. healthcare system for classifying diagnoses and health conditions.4Centers for Medicare & Medicaid Services. ICD-10 The code must match the clinical notes and lab results in the supporting documentation. Listing one diagnosis code while attaching notes that describe a different condition is one of the fastest ways to earn a denial.
For some specialty categories, especially biologics used in oncology, insurers may require genetic biomarker or laboratory results before they will approve the medication. Targeted cancer therapies, for example, often require proof that the patient’s tumor tested positive for a specific biomarker such as ALK, BRAF, or EGFR. If your medication falls into this category, attach the test results and the date they were performed.
Step Therapy History
Most specialty drug authorizations require evidence that the patient already tried lower-cost or first-line treatments before stepping up to the requested medication. This is called step therapy. The documentation should include the names of previously tried drugs, how long the patient took each one, and why each was discontinued, whether due to side effects, allergic reactions, or lack of response.5Centers for Medicare & Medicaid Services. Medicare Advantage Prior Authorization and Step Therapy for Part B Drugs
Be specific. “Patient failed methotrexate” is weaker than “Patient took methotrexate 15 mg weekly for 14 weeks with documented liver enzyme elevation requiring discontinuation.” Concrete failure history is harder for a reviewer to send back for more information. If the patient has a clinical reason to skip step therapy entirely, such as a documented contraindication to the first-line drug, spell that out with supporting lab work or specialist notes.
How To Submit the Form
Most ArchimedesRx prior authorization requests go in by fax. The fax number varies by health plan and is printed on the plan-specific version of the form. If you are using the general form and don’t see a fax number, contact ArchimedesRx member services or check your plan’s provider manual for the correct submission line.
Before faxing, run through a quick checklist:
- Every field is complete, with no blanks in the patient, insurance, prescriber, or medication sections.
- The ICD-10 code matches the clinical notes.
- Step therapy documentation is attached with drug names, durations, and reasons for discontinuation.
- Relevant lab results, imaging reports, or biomarker results are included.
- All pages are legible and oriented correctly. Pages that arrive sideways or cut off cause delays.
Keep a copy of everything you send, including the fax confirmation page. If a dispute comes up later about what was or wasn’t submitted, that confirmation sheet with the date, time, and page count is your proof.
How Long the Review Takes
Timing depends on the urgency of the request and the rules of your specific health plan. One plan-specific document from Independence Blue Cross states that the review can take up to two business days once all information has been received.6Independence Blue Cross. ArchimedesRx Prior Authorization Form Your plan may be faster or slower.
Federal rules set outer limits. For employer-sponsored group health plans and marketplace qualified health plans, a standard pre-service decision must come back within 15 days, extendable once by another 15 days with notice, and urgent care claims must be decided within 72 hours.7eCFR. 29 CFR 2560.503-1 – Claims Procedure Most plans set internal targets well below those maximums, so the practical turnaround for most ArchimedesRx requests is a few business days.
If the request is approved, both the provider and the patient receive a notification letter that spells out the approval duration, meaning how many months or refills are covered before a re-authorization is needed. Save this letter. You will need the approval reference number if any dispensing issues come up at the pharmacy.
If Your Request Is Denied
A denial letter must state the specific reason the request was turned down and describe how to appeal.8HealthCare.gov. Internal Appeals Read it carefully. Many denials are not medical disagreements but administrative gaps, such as a missing lab result or an incomplete step therapy history. In those cases, resubmitting with the missing information is often faster than filing a formal appeal.
Peer-to-Peer Review
Before or alongside a formal appeal, the prescribing physician can request a peer-to-peer review. This is a short phone call, usually five to ten minutes, between the prescriber and the insurer’s medical director to discuss why the medication is necessary. Peer-to-peer calls are typically scheduled within 24 to 72 hours of the request, and missing that window can result in the case being closed. The prescriber should have the patient’s chart, lab results, and step therapy history in hand during the call.
Internal Appeal
You have 180 days from the date you receive the denial notice to file an internal appeal. For a prior authorization denial, which concerns a service you haven’t received yet, the insurer must complete its internal appeal review within 30 days.8HealthCare.gov. Internal Appeals Include the denial letter, additional clinical documentation that addresses the stated reason for denial, and a letter from the prescriber explaining why the medication is medically necessary. Keep copies of everything and note the dates and names of anyone you speak with by phone.
External Review
If the internal appeal is also denied, you can request an independent external review by a third-party reviewer with no financial relationship to the insurer. The written request must be filed within four months of receiving the final internal denial. The external reviewer has up to 45 days for a standard decision, or 72 hours for an expedited decision when the medical situation is urgent.9HealthCare.gov. External Review The federal external review process is free.
Re-Authorization for Ongoing Treatment
An initial approval does not last forever. Most specialty drug authorizations cover a set number of months, commonly six or twelve, after which the provider must submit a new prior authorization to continue treatment. Don’t wait until the last refill. Submit the re-authorization at least two to four weeks before the current approval expires to avoid a gap in medication.
Re-authorization documentation is different from the initial request. Instead of proving the patient needs to start the drug, the provider needs to show the drug is working. Attach updated lab results, imaging, or clinical assessments that demonstrate improvement or stable disease compared to the baseline measurements taken before treatment began. Even a modest documented improvement in symptoms or test values strengthens the case. Include notes from recent visits that describe how the patient is responding and why continued therapy is recommended.
If the patient’s condition has changed, whether through a dose adjustment, a new complication, or a switch in how the drug is administered, note it on the re-authorization form and explain the clinical rationale. Reviewers flag unexplained changes in dosing or frequency, and addressing them up front prevents another round of follow-up questions.