Get Title Xix Home Health Durable Medical Equipment ... - Tmhp.com

This guide provides clear, step-by-step instructions on completing the Title XIX Home Health Durable Medical Equipment (DME) Physician Order Form. By following these steps, users can ensure that all necessary information is accurately submitted for efficient processing.

Follow the steps to accurately complete the form.

1. Click the ‘Get Form’ button to access the Title XIX Home Health Durable Medical Equipment form and open it for editing.
2. In Section A, indicate who completed this section by checking the appropriate box (Requesting Physician or Supplier). Then, provide the client’s name, Medicaid number, date of birth, and whether the client is under 21 years of age.
3. Fill in the supplier information, including the supplier name, Medicaid TPI number, address, city, state, zip code, telephone number, and fax number.
4. Enter the prescribing physician's name, telephone number, and fax number in the designated fields.
5. A certified representative from the DME/medical supplies provider must sign and date the form, confirming that the items prescribed are medically necessary and safely usable in the client's home.
6. For each requested item in Section A, provide the item number, HCPCS code, description, quantity, price, and indicate if prior authorization is required, if it exceeds quantity limits, or if it is a custom item.
7. If 'Yes' is checked for prior authorization, ensure to attach additional documentation to support medical necessity as outlined in the TMPPM.
8. In Section B, the prescribing physician must provide the ICD-9 codes, brief diagnosis descriptors, and justifications for medical necessity corresponding to each item in Section A.
9. Complete the fields for height, weight, wound stage or dimensions, and functionality/mobility status, if applicable.
10. It is mandatory to fill in the date last seen by the physician and the duration of need for DME and supplies in the appropriate sections.
11. The prescribing physician must then sign and date the form, attesting that the information correlates with the client’s medical necessity.
12. Finally, check all sections for completeness and accuracy before submitting the form as instructed.

Take the first step towards managing your documents online efficiently by completing the Title XIX Home Health Durable Medical Equipment form today.