Nc Dma Request For Prior Approval Cmn/pa Form

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NC DMA Request for Prior Approval CMN/PA
Recipient Information
DMA372-131
1. Recipient Last Name:__________________________
2. First Name:__________________________
3. Recipient ID #___________________
4. Recipient Date of Birth:______________
5. Recipient Gender:_________
Diagnosis Information
Diagnosis (code AND description)
Date of Onset
Primary?
1
2
Payer Information
6. Is this a Medicaid or Health Choice Request?
Medicaid:
Health Choice:
Provider Information
7. Requesting Provider #:_______________________________________NPI:
Atypical:
8. Taxonomy: ____________________
9. Address: _______________________________________________________________
10. Nine Digit Zip Code: ________________
11. Billing Provider #
:______________________NPI:
Atypical:
12. Taxonomy: _____________________
(if different from requesting)
13. Address: ______________________________________________________________
14. Nine Digit Zip Code: ________________
15. Rendering Provider #
:______________________NPI:
Atypical:
16. Taxonomy: ____________________
(if different from billing)
17. Address: _____________________________________________________________
18. Nine Digit Zip Code: ________________
Requester Contact Information Name:__________________________________
Phone #:_____________________
Ext:_______
Medical and Functional Status
19. Condition:
Stable:
Unstable:
Height: _________ Weight: ________
20. Prognosis:
Terminal:
Poor:
Guarded:
Fair:
Good:
Excellent:
21. Patient: Requires positioning not feasible in ordinary bed:
Unattended for long periods of time:
Lives alone:
22. Equipment: Necessary to retard deterioration of condition:
Necessary for function:
Specify_____________ Length of need: ______
23. Mental: Oriented:
Forgetful:
Disoriented:
Agitated:
Comatose:
Depressed:
Lethargic:
Infant:
Other: ______
24. Neurological: Muscle Tone:
Normal:
Increased:
Decreased:
Fluctuating:
Sensation:
Normal:
Abnormal:
Specify:___________
25. Respiratory:
Normal:
SOB on minimal exertion:
Tracheostomy:
O2:
Flow Rate:________ Frequency: __________
Test Date: ___________
Results: ______________
26. Skin:
Normal:
Other:
Specify: ____________
Decubiti:
Specify: __________________
27. Ambulatory: Complete bedrest:
Up as tolerated:
Transfers bed-chair (indep):
Transfers bed-chair (w/assistance):
Confined to wheelchair?
Hours per day: _____
Walks unassisted:
Walks with assistive device:
Specify: ____________ Max distance walked: __________
28. Can place of residence physically accommodate equipment being requested?
Yes
No
29. Patient’s status will be monitored by physician while assistance is provided?
Yes
No
30. Medical Necessity of equipment: _______________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Service Information
From Date
To Date
New/Used/Rental
HCPCS Code
Equipment Description
1
2
3
4
5
6
7
8
9
10
_____________________ ________
__________
_____________________ _____________
__________
Requesting Provider’s Signature
Date
Physician, PA, Nurse Practitioner Signature
Date
(M1) v 1.0

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