CLINICAL SERVICES
DME/Supply Prior Authorization/Pre-Service Determination Request

FAX TO 612-884-2499 or 1-866-610-7215

Review chapter 23 of our provider manual for coverage criteria and references. Submit documentation to support medical necessity along with this request. Please allow 14 days for a final determination. Failure to provide required documentation may result in denial of request.

*Requests will be verified with ordering prescriber. Accurate prescribing information is required.

Request date: _________
Member Name: __________________________________________________________
UCare ID: ______________________ DOB: ___________________

Member Address: ________________________________________________________

Assisted Living: House/Apartment Group Home/Foster Care Other facility ________________________ (name of facility)

*Ordering/Prescribing Provider Name: ____________________________NPI: ___________________

Ordering Provider address/Clinic: _______________________________________________________

Ordering Provider Phone Number: ___________________Fax#:_______________________________

DME Provider Name: ________________________________________________________________

Address: ___________________________________________________________________________

DME Provider (billing) NPI: __________________ Point of Contact Name: ____________________

Point of Contact Phone#: _________________Point of Contact Fax#:__________________________

· Purchase Anticipated date of purchase: _______________. Is this a replacement?

Yes No If yes- go to page 2, section A.

· Rental Date of delivery Is this a replacement?

Yes No If yes- go to page 2, section A.

· Wheelchair repair: go to page 2, section B.

· Pre-Service Determination: go to page 3, section C.

· Description (make, model, manufacturer): ______________________________________________________________________________

· HCPCS (include all):

______________________________________________________________________________

· Diagnosis (include all) Relevant to request:

_______________________________________________________________________________

· ICD10 codes: ______________________________________________________________________

DME REQUEST CONTINUED

A. Replacement information:

· Date of original purchase/delivery: ___________________

· Original payer: ________________________________________________________________

· Reason for replacement:_________________________________________________________

B. Wheelchair repair:

· Make/model/manufacturer: ________________________________________________________.

· Original payer: ___________________________________________________________________.

· Cost of Repair: ________________.

· Cost of replacement ________________.

C. Rationale for pre-service determination (select at least one):

UCare prior authorization requirement:

Coverage Criteria/Medical Necessity Criteria/Medical Policy determination:

Service/Procedure does not meet Original Medicare guidelines:

Quantity limit(s) exceeded according to Medicare or Medicaid:

Other: (please specify):________________________________________________________________

2 | Page DME Request form December 2015