Get Wvmi B

Filling out the Wvmi B form is a crucial step in obtaining authorization for medical supplies or durable medical equipment through Medicaid. This guide provides a clear and supportive walkthrough to assist users in completing the form accurately and efficiently.

Follow the steps to complete the Wvmi B form online.

1. Press the ‘Get Form’ button to access the Wvmi B form and initiate the process of filling it out online.
2. Enter the request date, member’s Medicaid ID number, and date of birth in the relevant fields. If Medicaid is not the primary payer, attach the denial for the requested items.
3. Fill out section A with the member's name, phone number, and address. Ensure the information is accurate and up-to-date.
4. In section B, input the prescribing practitioner's name, mailing address, contact name, phone number, extension, fax number, and email address. This information is vital for communication regarding the authorization request.
5. Complete section C by entering the DME vendor's name, physical address, provider number, phone number, and fax number. This identifies the vendor selected by the member.
6. In section D, provide the ICD-9 codes, clinical diagnosis, and date of onset of the condition requiring medical supplies or equipment.
7. Fill in section E with the HCPCS code, a description of the item requested, the length of need in months, and the quantity required. Be specific to ensure clarity for the authorization review.
8. Describe the clinical indications for the item(s) requested in section F. Use clear and concise language to explain the necessity of the medical supplies or equipment.
9. In section G, the prescribing practitioner must certify the information by signing and providing their Medicaid ID number and the date of certification. This ensures accountability and compliance with regulations.
10. Review all entries for accuracy and completeness. After confirming that all sections are filled out properly, save your changes, and you may choose to download, print, or share the completed Wvmi B form as needed.

Complete your Wvmi B form online today to ensure timely processing of your medical supplies authorization!