Get Dme Authorization Change Form - Geisinger Health Plan

Filling out the DME Authorization Change Form for Geisinger Health Plan online is a straightforward process. This guide will walk you through each section of the form, ensuring that you provide all necessary information accurately.

Follow the steps to complete the DME Authorization Change Form online.

1. Click 'Get Form' button to access the DME Authorization Change Form and open it for editing.
2. Begin by filling out the 'DME Vendor' field with the name of your durable medical equipment provider. Ensure that this information is correct to avoid delays.
3. Next, enter the 'Location' where the equipment will be delivered or picked up. This helps in coordinating logistics effectively.
4. Input the 'Phone Number' for your DME vendor. Providing accurate contact details is crucial for any follow-up needed.
5. If applicable, include the 'GHP Provider Number' in the designated field. This links the request to your healthcare provider.
6. Fill in the 'Fax Number' of the vendor if it is relevant for sending documents. This is important for efficient communication.
7. Clearly indicate the 'Change Requested' by selecting one of the options: Date of Service, Change of Equipment, or Code Change. Make sure to specify the details in the next fields.
8. Complete the 'Form Completed By' section, providing your name or the name of the individual who is completing the form.
9. Enter the 'Member ID' of the individual requesting the equipment and include their 'Member Name' for identification.
10. Fill in the 'Auth Number' provided to you for this authorization request. This ensures that your request is processed under the correct authorization.
11. Provide the 'HCPCS authed' and 'HCPCS requested' codes related to the equipment for which you are seeking authorization. This is important for billing purposes.
12. If there is a vendor-specific request or reason, detail this information in the relevant fields to provide clarity.
13. Indicate the 'Adjusted Date of Delivery,' 'Equipment Change Date,' and 'Return or Pick-up Date' as needed to give precise timelines.
14. Review all entered information for accuracy. Incomplete forms will be returned unprocessed, so it is essential to ensure all required fields marked with an asterisk are filled out.
15. Once all information is complete and verified, you can save the form, download it, print it, or share it as needed.

Complete your DME Authorization Change Form online today to ensure timely processing.