Get Nj Horizon Health Dme Authorization Request Form 2018-2025

The NJ Horizon Health DME Authorization Request Form is essential for obtaining prior authorization for durable medical equipment. This guide provides clear, step-by-step instructions on how to fill out the form online, ensuring that all necessary information is accurately submitted.

Follow the steps to complete the form online smoothly.

1. Press the ‘Get Form’ button to access the NJ Horizon Health DME Authorization Request Form.
2. Fill in the general information section with the member's name, member ID number, date of birth, address, and phone number.
3. Complete the DME provider's details, including the provider's name, contact person's name, contact phone number, and fax number.
4. In the medical information section, enter the date or date range of service, and specify the primary diagnosis and any other chronic diagnoses.
5. Provide the necessary ICD-10 codes related to the member's condition. You will need to list multiple codes if applicable.
6. Fill in the required information for the durable medical equipment (DME) being requested, including the HCPC code and quantity.
7. Enter the ordering physician's name along with their provider ID and NPI numbers.
8. Complete the DME servicing provider's information, including their provider ID.
9. Indicate whether this is an initial authorization request or an extension request. If it's an extension, include the previous authorization number.
10. If necessary, add any comments that may support the request.
11. Once all sections are filled out, review the form for accuracy. You can then save your changes, download, print, or share the completed form as needed.

Ensure your request is submitted accurately by following these steps to fill out the form online today.