Get Dme Ancillary Services Authorization Request

Completing the DME Ancillary Services Authorization Request is essential to ensure that members receive appropriate services and that claims are processed smoothly. This guide will provide you with clear, step-by-step instructions on how to fill out the form effectively online.

Follow the steps to complete the authorization request form accurately.

1. Click ‘Get Form’ button to obtain the DME Ancillary Services Authorization Request form and open it in your preferred editor.
2. In the member information section, enter the required details including the WellCare ID, last name, first name, Medicaid or Medicare number, phone number, and date of birth.
3. Proceed to the ordering provider information section. Fill in the WellCare ID number, NPI number, last name, first name, street address, city, state, phone number, fax number, provider type or specialty, name of requester, and zip code.
4. If applicable, complete the treating provider/vendor section. You can check the box to skip this section and have the Plan assign a provider/vendor, or fill in the details as needed.
5. Select the type of facility where services will be provided, choosing either 'Office' or 'Home'.
6. In the service requested section, fill out the planned date of service, primary ICD-10 code, CPT-4 or HCPC code, and descriptions of the requested procedure or services, including units if necessary.
7. Provide a total amount billed for DME and include a pertinent clinical summary. Attach any supporting clinical records if necessary and include specific member information for customized equipment or services.
8. Review all entries for accuracy before finalizing the form. Once satisfied, you can save changes, download the form, print it, or share it as needed.

Complete your DME Ancillary Services Authorization Request online today to ensure timely and appropriate care.