Get Dmas 98r

Filling out the Dmas 98r form online can streamline the submission process for home and community-based services requests. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to effectively complete the Dmas 98r form online.

1. Click ‘Get Form’ button to access the Dmas 98r and open it in the online editor.
2. Select the request type by placing a checkmark in the appropriate box for either New Request or Change Request.
3. Enter the Date of Request in the format MM/DD/YYYY.
4. Provide the Member Phone Number, ensuring to include the area code; if unavailable, input N/A.
5. Input the Member Last Name exactly as it appears on the Medicaid card.
6. Input the Member First Name exactly as it appears on the Medicaid card.
7. Enter the Date of Birth in the format MM/DD/YYYY.
8. Indicate the Gender by placing a checkmark for Male or Female.
9. Complete the Service Provider Information section, including the Provider Name, NPI/API Provider ID Number, Provider Street Address and City, and the 9-digit zip code.
10. Provide the Primary Diagnosis Code/Description that indicates the reason for the services requested.
11. If necessary, fill out the Additional Information section for any extra details regarding the request.
12. Select the Service Authorization Type by checking the appropriate box.
13. Detail the Justification/Need for the service requested based on the guidelines.
14. Add any Additional Comments to support the request.
15. Provide the Procedure Code (National Code) relevant to the service being requested.
16. Write a Narrative Description explaining the Procedure Code.
17. Input any Modifiers, if applicable.
18. State the Units/Hours Requested based on the physician's orders.
19. Include the Frequency of service visits as specified in the Plan of Care.
20. If applicable, detail the Actual Cost per Unit for services like Assistive Technology or Environmental Modifications.
21. Indicate the Total Dollars Requested, if necessary.
22. Fill in the planned Dates of Service, ensuring both the From and Thru dates are completed.
23. Provide the Provider Contact Person’s name for any inquiries.
24. Input the Provider Contact Phone Number.
25. Finally, provide the Provider Contact Fax Number for any communications regarding the request.
26. Save changes, download, print, or share the completed form as needed.

Complete your Dmas 98r form online today for a streamlined service request process.