Wv Medicaid Dme Prior Authorization Request Form (Dme)
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3WV MEDICAID PRIOR AUTHORIZATION FORM
FAX 1-844-633-8429 DME
Today’s Date ___________________
REGISTRATION ON C3 IS REQUIRED TO SUBMIT PRIOR AUTHORIZATION REQUESTS WHETHER BY FAX OR ELECTRONICALLY.
DETERMINATIONS ARE AVAILABLE ON
C3 Requesting/Submitting Organization
________________________________________________________ Please list exactly as registered on C3
Address, City, State, Zip
_______________________________________________________________________________________
C3 Requesting/Submitting Organization NPI
________________________________________________________ Please list exactly as registered on C3
Person Submitting Request _____________________ Phone ____________________ Fax _____________________ Email_________________________
Referring/Ordering Provider
(Per policy the Referring/Ordering Provider must be actively enrolled with WV Medicaid)
Name
NPI Number
Do not write “See Above”
Contact Information
Phone
Fax:
Place of Service/Servicing Provider
(Per policy the Place of Service/Servicing Provider must be actively enrolled with WV Medicaid)
Name
NPI Number
Do not write “See Above”
Address,
City, State, Zip
Member Medicaid Number ________________________________________________ DOB_______________________
Member First Name
______________________________________________
Last Name __________________________________________
Member Address, City, State, ZIP
_______________________________________________________________________________________________
Procedure Type:
DME
Type of Admission/Procedure:
Emergency/Medically Urgent
Non-Urgent
List Other Retrospective Reason:
Authorization Type:
Prior Authorization
Retrospective Request, when applicable list the appropriate reason:
Denied by Member’s Primary Payer
Retrospective Medicaid Eligibility
Request Type:
New
Repair
Replacement
Length of Time Needed:
Days
Months
Ongoing
Permanent
Weeks
Years
For Members under age 21:
1.
Is this request an EPSDT referral?
Yes
NO *If yes, please submit the most current EPSDT form on file*
2.
Does member have an Individual Education Plan(IEP) that includes these services?
Yes
No *If yes, please attach a copy.
DOCUMENTS TO BE SUBMITTED:
Certificate of Medical Necessity
Date of CMN
__________________
Yes
No
•
START DATE
Signed Physician’s Order(s)
Date of Order
__________________
Yes
No
•
Most Recent Progress Notes
Date of Notes
__________________
Yes
No
N/A
•
Waiver Letter for School-Aged Children
Date of Letter
__________________
Yes
No
N/A
•
Treatment Care Plan
Date of TCP
__________________
Yes
No
N/A
•
Members <21 Individual Education Plan
Date of IEP
__________________
Yes
No
N/A
•
OTHER DOCUMENTS ATTACHED _______________________________________________________________________
•
____________________________________________________________________________________________________
**I certify that this patient meets the program eligibility criteria and that this equipment is a part of the course of treatment and is reasonable,
medically necessary and is most cost effective and is not a convenience item for the recipient, family, attending practitioner or supplier. To my
knowledge, the information included on this application is accurate.
Yes
No
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