Montana Medicaid Prior Authorization Request Form

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Medicaid
Montana Medicaid Prior Authorization Request Form
Durable Medical Equipment (DME) and Supplies (Rev. October 2014)
Patient Name, Address, Telephone Number, Date of Birth
Supplier Name, Address, Telephone Number
Medicaid ID Number ____________________________________
NPI Number ____________________________________
Other Insurance
Physician Name, Address, Telephone Number
Residence
Home
Nursing Home
Hospital Rehab Unit
Group Home
Other _______________________________
Does the patient have the ability to operate/use this requested item as intended by the items manufacture?
Yes
No
Has the patient received a trial use of this item?
Yes
No
If yes, for how long? ______________
Was the item billed to Medicaid as a rental during the trial use period?
Yes
No
Is the product or its components covered by a warranty?
Yes If yes, attach warranty information.
No
Specification List
NOTE: All billable items that make up this request must be listed individually below. Any item that is not listed below is subject to recovery if
added and billed to Medicaid at a later time. If additional space is needed, a continued sheet can be attached to this document as long as the pertinent
patient and supplier information is included at the top of the attachment.
LEVEL II
LIST
DEPT. USE
DOS
DESCRIPTION
MANUFACTURER
PRODUCT #
UNITS
CODE
PRICE
ONLY
I certify that the information contained in this document and its attachments/supporting documents are true, accurate, and complete, to the best of my
knowledge. I further certify that all measurements, fitting, assembly, and adjustments have been completed, or will be completed upon delivery. I
understand my responsibility to train the patient and/or caregiver in the proper use and advise any safety issues of the requested item. I understand that
any falsification, omission, or concealment of material fact in this document may subject me to civil or criminal liability.
Signature and date stamps are not acceptable.
Supplier Signature
Date
Attachments: This form must be accompanied by copies of supporting documentation to justify the medical need of the requested items. Supporting
documentation includes, but is not limited to a prescription, Certificate of Medical Need (if required of the item), and a narrative description detailing
the need for the item from the patient’s primary care provider. If the patient is being treated by a licensed therapist, a copy of the patient’s plan of care
and a narrative summary supporting this request is required.

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