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Elizabeth M. Whitehorn, Director

Provider Notice issued 06/23/15

New and Revised Forms for Prior Approval of Specific Durable Medical Equipment

To:​ Durable Medical Equipment and Supplies Providers; Hospitals; and Pharmacies​
Date:​ ​June 23, 2015
​Re: New and Revised Forms for Prior Approval of Specific Durable Medical Equipment ​

The department has developed new DME forms, and revised some existing ones, to better identify to providers the information required by the department for review of prior approval requests.

Effective with the date of this notice, HFS will require that providers submit these forms in addition to any clinical information that supports medical necessity, plus the existing HFS 1409 Prior Approval Request (pdf) form for the specified DME items. A valid physician/practitioner order is also required.

All of the forms referenced below are available in a PDF-fillable format on the department’s Medical Programs Forms page. Please note that the department has recently created a new Medical Prior Approval Criteria webpage. All prior approval forms can also be accessed at that site.  

As a reminder, any request for “custom” equipment must have documentation to support the need.

Revised HFS Forms:

  • HFS 3701G     Special Decubitus Mattress Questionnaire

  • HFS 3785        Questionnaire for Negative Pressure Wound Therapy

  • HFS 3785A     Progress Report for Negative Pressure Wound Therapy

New HFS Forms:

  • HFS 2305        Wound Measurement Assessment Form

  • HFS 2305A     Air Fluidized Bed Questionnaire

  • HFS 2305B     Questionnaire for Airway Clearance Device

  • HFS 2305C     Questionnaire for Continued Rental of Airway Clearance Device

  • HFS 2305D     Certificate of Medical Necessity for Continuation of External Insulin Infusion Pump

  • HFS 2305E     Questionnaire and Order for Cranial Remolding Orthosis or Cranial Cervical Orthosis Congenital Torticollis Type

  • HFS 2305F     Certificate of Medical Necessity for External Insulin Infusion Pump

  • HFS 2305G     Questionnaire for Home Apnea Monitor

  • HFS 2305H     Questionnaire for Home Phototherapy

  • HFS 2305I       Questionnaire and Order for Neuromuscular Electrical Stimulator (NMES)

  • HFS 2305J      Questionnaire for Prosthesis

  • HFS 2305K     Compression/Burn Garments Questionnaire

  • HFS 2305L      Informed Consent for Future LifeVest Rental Related to Compliance with Cumulative Wear Time

  • HFS 2305M    Knee Brace Questionnaire

  • HFS 2305N     Questionnaire for Orthosis

Note: The instructions in this notice apply to patients enrolled in traditional fee-for-service, Accountable Care Entities (ACEs), and Care Coordination Entities (CCEs), and do not apply to patients enrolled in Managed Care Organizations (MCOs) and Managed Care Community Networks (MCCNs).

It is imperative that providers check HFS electronic eligibility systems regularly to determine beneficiaries’ enrollment in a plan. Electronic Data Interchange vendors (formerly the Recipient Eligibility Verification (REV) System), the Automated Voice Response System (AVRS) at 1-800-842-1461, and the Medical Electronic Data Interchange (MEDI) system will identify any care coordination plan in which the beneficiary is enrolled. Plan contact information for questions related to coverage and billing requirements, as well as information regarding the way each plan is displayed in the department’s electronic eligibility systems may be located in the June 24, 2014 informational notice titled, Revised - Care Coordination Enrollment for Children, Families and ACA Adults (pdf).

Any questions regarding this notice may be directed to the DME Prior Approval unit in the Bureau of Professional and Ancillary Services at 1-217-524-0009.

 

Felicia F. Norwood

Director