Get Durable Medical Equipment/wheelchair Request Prior Authorization Form - Providers - Amerihealth

This guide provides a clear and comprehensive approach to completing the Durable Medical Equipment/Wheelchair Request Prior Authorization Form for providers associated with AmeriHealth. By following the outlined steps, users can efficiently submit their requests online, ensuring all necessary information is accurately provided.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the Durable Medical Equipment/Wheelchair Request Prior Authorization Form and open it in the designated form editor.
2. Fill in the contact information at the top of the form, including the contact name, phone number, and fax number.
3. Complete the participant information section. Enter the participant's name, ID number, date of birth, phone number, primary insurer participant ID, and primary authorization number.
4. Input the physician's contact information, including their phone number and fax number, as well as the DME vendor’s phone number and fax number.
5. Specify the dates of service and indicate whether the request is for purchase or rental. Include the authorization number if applicable and the name of the carrier.
6. In the provider information section, list the physician's name, NPI, DME vendor name, and vendor NPI.
7. Provide the necessary codes. Fill in the ICD diagnosis code, HCPC code, units per month, and billing amount. Ensure accuracy for the wheelchair or powered vehicle.
8. Remember that a home assessment is required for manual wheelchairs, power wheelchairs, and scooters. Also, include the DHS Prescription form for all power wheelchairs and scooter requests.
9. Include clinical notes supporting the medical need for the requested service. These should include a current script listing frequency and duration, and note that scripts must be updated every six months.
10. Review the important payment notice section to ensure compliance with ordering/referring/prescribing requirements. Confirm the validity of the Pennsylvania Medical Assistance Provider ID.
11. At the end of the form, complete any additional information required and make sure all fields are filled for processing. Finally, save changes, download, print, or share the form as needed.

Start filling out the Durable Medical Equipment/Wheelchair Request Prior Authorization Form online today.