Get Wv Medicaid Dme Prior Authorization Request Form - Aps Healthcare

This guide provides a clear and comprehensive approach to completing the WV Medicaid DME Prior Authorization Request Form through online means. By following these instructions, users can ensure accurate submission of their requests for durable medical equipment.

Follow the steps to effectively complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Start by entering today's date in the designated space at the top of the form.
3. In the 'C3 Requesting/Submitting Organization' section, provide the name as registered on C3, followed by the address, city, state, and zip code.
4. Next, enter the NPI number associated with the requesting organization.
5. Fill in the 'Person Submitting Request' section with the full name, phone number, fax number, and email address of the individual submitting the request.
6. Provide details of the referring/ordering provider, ensuring to include their name (not “See Above”), NPI number, and contact information.
7. For the place of service/servicing provider, repeat the entry process as completed for the referring provider, ensuring to include the name, NPI number, and their address.
8. Enter the member’s Medicaid number and date of birth, along with their first name, last name, and address.
9. Select the procedure type as DME and specify the authorization type.
10. Choose the type of admission/procedure (Emergency/Medically Urgent or Non-Urgent) and include any other applicable retrospective reasons.
11. Indicate the request type (New), length of time needed, and fill out the relevant options for ongoing, repair or replacement equipment needed.
12. For members under age 21, answer the EPSDT referral and IEP questions accurately.
13. Gather and attach the necessary documentation required as outlined in the form, ensuring all supporting documents are included.
14. Certify the patient's eligibility by checking the provided statement and signing as required.
15. Finally, provide the list of DME CPT/HCPC codes, along with quantities, frequency of use, and included clinical indications, as needed.
16. Once all sections are completed, users can choose to save changes, download the completed form, print, or share it as necessary.

Complete your WV Medicaid DME Prior Authorization Request Form online to ensure timely processing of your request.