Get Home Telemonitoring Services Prior Authorization ... - Tmhp.com

This guide provides comprehensive instructions for completing the Home Telemonitoring Services Prior Authorization request form. By following these steps, users can ensure a smooth and accurate submission, facilitating necessary telemonitoring services.

Follow the steps to fill out the form accurately and efficiently.

1. Press the ‘Get Form’ button to acquire the Home Telemonitoring Services Prior Authorization request form and open it for editing.
2. Complete Section A with client information. This section requires the following details: first name, last name, Medicaid number, and date of birth.
3. In Section B, provide the requested telemonitoring service information, including the home telemonitoring qualifying diagnosis and the requested dates of service. Indicate the physician-ordered frequency of clinical data transmission and any optional comments.
4. For client risk factors in Section B, check all applicable items related to hospitalizations, emergency department visits, medication adherence, falls, support systems, living situations, and care access challenges.
5. Proceed to Section C and fill in the physician information, including TPI or NPI numbers and the physician’s signature. Ensure that one of the allowed documents (prescription, written order, or documented verbal order) is attached if the signature is not present.
6. In Section D, enter telemonitoring provider information, specifying the provider's printed name, contact person, address, telephone number, fax number, TPI, NPI, and date signed.
7. Once all sections are complete, review your entries for accuracy. You can then save changes, download the form, print it for physical submission, or share it as needed.

Take the first step to ensure smooth telemonitoring services by completing the Home Telemonitoring Services Prior Authorization request form online.