Get Emedny361501

Filling out the Emedny361501 form is essential for obtaining prior approval for durable medical equipment under the New York State Medicaid Program. This guide provides clear and supportive instructions to help users navigate through each section of the form effectively.

Follow the steps to successfully complete the Emedny361501 form.

1. Click the ‘Get Form’ button to access the Emedny361501 form and open it in your preferred online editor.
2. Fill in the 'Prior Approval Request Type' field by placing an 'X' in the appropriate box that corresponds to the type of service or supply for which prior approval is being requested.
3. In the 'Order Date' field, enter the date on which the order was initiated using the format MMDDYYYY, for example, October 7, 2005 = 10072005.
4. Provide the Prescribing Provider's ID or license number in the 'ID / License Number' field. Ensure to justify the information to the right and follow the format as specified in the guidelines.
5. Enter the appropriate 'Profession Code' for the Prescribing Provider in the 'Prof Code' field, referring to the defined codes based on their profession.
6. Print the Prescribing Provider's name in the 'Prescribed By (Name)' field, with the last name followed by the first name.
7. Fill in the Prescribing Provider’s address in the 'Address' field, including facility name if applicable.
8. Input the Prescribing Provider's telephone number in the 'Provider Telephone Number' field.
9. Ensure the Prescriber signs the form in the 'Prescriber Signature' field, unless a fiscal order is written on a different document, in which case state 'Appears on Order'.
10. Complete the 'Primary Diagnosis' and 'Secondary Diagnosis' fields with the appropriate ICD-9-CM diagnosis codes.
11. Input the Client's eight-character alphanumeric Welfare Management System (WMS) ID Number in the 'Client ID' field.
12. Enter the Client's name and address as they appear on the Common Benefit ID Card.
13. Fill in the Client's date of birth in the 'Date of Birth' field using the format MMDDYYYY.
14. Input the Client’s telephone number in the 'Client Telephone Number' field, and ensure the sex matches the Common Benefit ID Card by marking 'M' for Male or 'F' for Female in the 'Sex' field.
15. Provide a detailed 'Order Description / Medical Justification' for the equipment or service being requested, indicating medical necessity, patient details, and any necessary justifications.
16. Enter the Servicing Provider's eight-digit MMIS identification number in the 'Servicing Provider ID' field and ensure the 'Servicing Provider Name' and 'Address' fields reflect the correct information.
17. Fill in the 'Procedure / Item Code' field with the appropriate five-character code as specified in the New York State Procedure Code Section.
18. Indicate if the item is a rental in the 'Rental?' field by placing an 'X' in the appropriate box.
19. Enter the corresponding description for the item in the 'Description' field.
20. Specify the 'Quantity Requested' and 'Times Requested' fields appropriately, filling in the required numbers based on the request details.
21. Calculate and enter the 'Total Amount Requested' for the items requested.
22. Finally, complete the 'PA Review Office Code' field with the appropriate state agency code responsible for prior approval.
23. Once all fields are filled accurately, save your changes, download, print, or share the completed form as required.

Complete the Emedny361501 form online today for faster processing of your prior approval requests.