Get Mobility Assessment And Prior Authorization (pa) Request - Medicaid Nv

Completing the Mobility Assessment And Prior Authorization (PA) Request form is a crucial step in obtaining necessary mobility devices for individuals with disabilities. This guide provides clear, step-by-step instructions to assist users in efficiently filling out the form online.

Follow the steps to successfully complete your Mobility Assessment and Prior Authorization request.

1. Click ‘Get Form’ button to acquire the form and open it in your preferred online editor.
2. In Section I, Prior Authorization (PA) Information, enter the PA request date, assessment date, and prescription order date. Select the request type (initial, continued services, retrospective, unscheduled revision) as applicable.
3. For retrospective requests, provide the Medicaid eligibility determination date. For children under 21, indicate whether the request is a result of EPSDT Healthy Kids services.
4. In the Recipient Information section, fill in the recipient's name, ID, date of birth, age, sex, phone, address, and location. Ensure the recipient's name matches Medicaid records.
5. Complete information regarding the recipient's current location, length of residency, and any Medicare coverage or other insurance details.
6. In Section II, Current Equipment/Devices, check which mobility devices the recipient currently uses and provide specifics such as make, model, and age of the equipment. If requesting replacement, detail the reason.
7. List the specific mobility-related activities of daily living (MRADLs) the recipient is unable to perform with current devices and explain if modifications are possible.
8. In Section III, Clinical Assessment, detail the recipient's diagnoses and any relevant medical conditions. Attach additional documentation as needed.
9. Complete Section IV, Physical Assessment, with details regarding postural control, functional abilities, and existing mobility-related issues.
10. Proceed to Section V, Mobility Related Activities of Daily Living (MRADLs), to describe the recipient's daily routine, living situation, and supportive services.
11. In Section VI, Seating and Positioning Considerations, provide the recipient’s measurements and specific needs for any requested seating systems or accessories.
12. Detail environmental considerations in Section VII, including the recipient's home accessibility and potential issues with the requested equipment.
13. In Section VIII, Prior Authorization Summary, summarize the requested items with HCPCS codes and required documentation.
14. Complete the Attestation Statements and Signatures section, ensuring all relevant parties attest to their independent relationship with the DME provider.
15. Finally, review the form for completeness, save your changes, and then download or print the document for submission.

Prepare your request today and complete the Mobility Assessment And Prior Authorization form online for the equipment you need.