Provider Notice issued 10/23/07

Revisions to DME Questionnaires and Posting to Web Site

The department has revised several DME questionnaires associated with requests for prior approval.  These revised questionnaires, as well as some additional DME documents, have been added to the department’s Web site at <http://www.hfs.illinois.gov/medicalforms/> for downloading and use. 

The following questionnaires have historically been contained in Chapter M-200, Handbook for Providers of Medical Equipment and Supplies.  At the time the handbook is revised, the appendices containing the questionnaires will be removed.  These questionnaires have been placed on the department’s Web site for downloading and use:

• Appendix M-5 – The 3701F, C-PAP/Bi-PAP Rental Request, has been revised and renamed the C-PAP/BiPAP Renewal Questionnaire.  For the first three-month trial period, the department requires a physician order and sleep study with the Prior Approval Request, which is sufficient documentation for the initial approval.  The revised 3701F must be submitted for continuation of the rental period beyond the initial three-month period. 

• Appendix M-6 – The 3701H, Power Wheelchair Questionnaire, was replaced effective August 1, 2006, with the HFS 3701H, Seating and Mobility Evaluation, and the HFS 3701K, Power Mobility Devices and Custom Manual Wheelchairs Physician’s Form.  Both of these forms have been revised.  In addition, the instructions document, “Required Documentation for Power Mobility Devices and Custom Manual Wheelchairs Requests”, has been updated and placed with the 3701H and 3701K on the Web site. 

• Appendix M-7 – The 3701E, TENS Unit Questionnaire, remains unchanged.

• Appendix M-8 – The 3701G, Special Decubitus Mattress Questionnaire, remains unchanged.

The following questionnaires are not part of the handbook, but have also been added to the Web site for downloading and use:

• 3640 – Augmentative Communication System Assessment Review Checklist

• 3641 - Augmentative Communication System Client Assessment Report

• 3785 – Questionnaire for Specialized Wound Therapy

• 3785A – Progress Report for Specialized Wound Therapy

The following form will no longer be required:

• Appendix M-9, the 314A – Request for Approval for Orthotic Services.  A physician’s order will replace the use of the 314A form.

At this time, none of the documents posted to the Web site are in a fillable format.  Providers must print off these forms from the Web site for completion.  Please destroy all copies of the old versions of these documents and obtain the newest versions from the Web site.
 
Any questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator
Division of Medical Programs

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