Get Prior Authorization For Hearing Aids Attach Invoice

This guide provides a clear and supportive approach to filling out the Prior Authorization for Hearing Aids Attach Invoice form online. By following these steps, users will ensure that the form is completed accurately to facilitate a smooth authorization process.

Follow the steps to complete the form accurately

1. Click ‘Get Form’ button to access the form and open it in the designated editor.
2. Enter the client Medicaid number in the first field. This is the eleven-digit identification number assigned to the client by Nebraska Medicaid.
3. Input the hearing aid dispenser's National Provider Identifier (NPI) in the designated field. This should be the ten-digit NPI specific to the dispenser.
4. Enter the contact phone number of the person responsible for the authorization request in the designated field.
5. In the section for services to be authorized, enter details for up to four services: for each entry, provide the procedure code, modifier if applicable, description of the service, and amount — using ‘IC’ for items paid at invoice cost.
6. Input the physician's name who signed the DM-5H form regarding hearing loss.
7. Select the appropriate ICD version indicator by checking the relevant box for the date of service.
8. Ensure all fields are completed accurately before attaching the completed DM-5H form to the MC-9HA form.
9. Finally, save your changes, download, print, or share the completed form as needed.

Start filling out your documents online today to ensure timely processing.