Elderly Waiver Prior Authorization Request

Specialized Supplies and Equipment (T2029)

Please complete and fax this form to the Blue Plus Utilization Management department at 651-662-4022 or 866-800-1665 to request a prior authorization for the following:

1.  Seat portion of lift chair over $800.00

2.  Specialized Supplies and Equipment Items (T2029) over $500.00

3.  An exception for items listed as not covered by the Elderly Waiver (EW) Specialized Supplies and Equipment (T2029) Guide

Member Name ID: Date of Birth:

Relevant Diagnosis

Care Coordinator Name: Delegate Agency: CC’s Phone #: CC’sFax #: CC’s Email:

Durable Medical Equipment Provider Name:

Provider Phone #: Provider Fax #:

1. Seat Portion of Lift Chair over $800.00

For a chair quote priced greater than $800.00, the following additional information is required:

§  Documentation specifically detailing the need for each additional feature adding to the basic cost of the chair as well as the medical or remedial need for the additional features:

§  Attach itemized quote detailing the cost of the chair and each feature separately.

2. Specialized Equipment Item/T2029 over $500.00

Description and cost (fax additional documentation if needed):

Include in documentation all of the following:

§  Rationale for item.

§  How will item prevent institutional placement?

§  Is this the most cost effective alternative?

§  What alternatives have been tried and failed or considered prior to this request?

3. Exceptions: Items listed as not covered by Elderly Waiver (EW) on the Specialized Supplies and Equipment/T2029 Guide

Item Description and cost (fax additional documentation if needed):

Include in documentation:

§  Extenuating circumstances that warrant an exception to the SSE/T2029 Guide.

§  How will item prevent institutional placement?

§  Is this the most cost effective alternative?

§  What alternatives have been tried and failed or considered prior to this request?

Fax this completed form and any additional documentation, if applicable, to the Blue Plus Utilization Management department at 651-662-4022 or 866-800-1665.