Form Dvha 60 - Medical Necessity Form (Mnf) (Page 2 of 2) in pdf

DVHA 60

Section B FOR DURABLE MEDICAL EQUIPMENT AND SUPPLIES (completed by the DME vendor)

10. Date supplies/equipment first placed in the home____/___/____

11. List equipment currently in home relevant to item(s) requested:

Rented? (Yes or No)

Signature of DME employee completing above information:__________________ phone#___________

Medicaid DME provider #______________________________________

The DME supplier must include a copy of this MNF with every Prior Authorization (PA) request. See the DME

Provider Manual for procedure codes which require PA or a MNF to be submitted with the claim. Exceptions to

this rule include certain prosthetics (ostomy supplies and those prostheses which replace a missing body part),

urologic supplies and diabetic supplies. For these items, the MNF need only be kept in the patient record, not

sent in with the claim. DME supplier fax request to the DVHA (802) 879-5963

For all items, the provider may attach a separate page with the treatment plan, PT or OT notes,

explanation, and/or relevant progress notes.

A &

*INSTRUCTIONS FOR SECTIONS

Section A must be completed or reviewed, signed and dated by the ordering physician.

Section B must be completed by the DME vendor when equipment and/or supplies are ordered

1. Patient’s first & last name, date of birth (DOB) and Medicaid ID number.

2. Print all related diagnoses, including status diagnoses such as colostomy, tracheostomy. If this is an initial

order or there have been significant clinical changes, attach documentation reflecting the physician’s

treatment plan.

3. Must answer yes or no. If no (if the ordered item is to be used in a place of service other than the patient’s

home(, the name and address of that facility is required.

4. Check all functional levels which apply (for commodes, an explanation is required as to why this patient

cannot use regular bathroom facilities)

5. List each item being ordered, date of the initial order, purpose (for example, softwick sponges for

tracheostomy or saline for open wound care), expected length of need (will be interpreted as months

unless stated otherwise), and the number of items needed (eg, 60 softwick sponges per month, 2 bottles

of sterile saline per month).

NOTE: If the quantity ordered is more than the number allowed (based on customary usage and

given in the DME Provider Manual), an explanation from the physician will be needed.

6. Whenever the item being ordered is related to a fracture, accident, congenital birth defect, etc. and/or when

there has been related surgery, give the date of that event and/or the date of surgery.

7. Print the ordering/signing physician’s name, address and phone number (must be legible).

8. This signature must be that of the ordering physician and attests to the validity of the information given. The

date of this signature is also required. The physician’s individual Medicaid provider # is necessary so the

DME vendor can bill.

9. To be completed by the DME vendor: When the ordered item is equipment, rented or purchased, these

two date fields are mandatory.

10. To be completed by the DME vendor: List all equipment now in the home for use for this patient (eg,

suction machine, ventilator, oxygen concentrator, semi-electric bed, nebulizer, oxygen or compressed air

tanks, wheelchair, walker, commode, etc...) and for each, state yes if it is being rented or no if it is not rented

equipment.

Form Dvha 60 - Medical Necessity Form (Mnf) Page 2