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Elizabeth M. Whitehorn, Director

Provider Notice Issued 04/10/2025

 

To: Enrolled Durable Medical Equipment and Supplies Providers
​Date April 10, 2025
​Re:
 New Durable Medical Equipment Forms Required for Prior Approval Requests

The Department of Healthcare and Family Services (HFS) has developed six new durable medical equipment (DME) forms to better identify to providers the information required by HFS for review of prior approval requests. Effective with the date of this notice, HFS will require that providers submit these forms in addition to the existing HFS 1409 Prior Approval Request form for specified DME items.

All of the new forms referenced below are available in a PDF-fillable format on HFS’ Medical Prior Approval Criteria webpage, as well as the Medical Programs Forms page.

·         HFS 2305 P – Neurogenic Bowel Dysfunction Questionnaire for the Adult Customer at Least 18 Years Old

·         HFS 2305 Q – Neurogenic Bowel Dysfunction Questionnaire for the Pediatric Customer

·         HFS 2305 R – Questionnaire for Use of Transanal Irrigation System

·         HFS 2305 S – Questionnaire for Continued Use of Transanal Irrigation System

·         HFS 2305 T – Annual Prosthetic Fit & Function Follow-Up

·         HFS 2305 U – Microprocessor as Initial Prosthetic Component Agreement

Questions regarding this notice may be directed to the DME Prior Approval unit in the Bureau of Comprehensive Health Services at 1-877-782-5565, option 2, 3, then 2.

 

Kelly Cunningham, Administrator
Division of Medicaid Programs