Ia Health Link Certificate Of Medical Necessity For Waiver Assistive Devices Template

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Certificate of Medical Necessity for
Waiver Assistive Devices
Use this form as your cover page. Fax to Utilization Management Waiver Prior Authorization 844-399-0479 .
(Please print or type clearly – accuracy is important)
Section A
1. Member Name (Last)
(First)
(Initial)
2. Case Manager Name
3. Medicaid SID #
4. Date of Birth
5. Service Plan Dates Covered by Request
From
To
Month
Day
Year
Month
Day
Year
6. Name of Item Requested:
7. Type of Review Being Requested:
Remember to attach all documentation.
8. Documentation attached?
Yes
No
Initial
Continued Stay Review (CSR)
(see Section D)
Revised form
Re-review
9. Number of pages including this one:
Section B Answer ALL Questions 1 through 6 for Assistive Devices
1. Have other funding sources been tried? Outline in Section C.
Yes
No
Community services fund
Family
Other
Charitable organizations
State plan durable medical equipment
Yes
No
2. Is this device covered by other funding sources? Outline in Section C.
Yes
No
3. Will the device increase or maintain independence of the member? Outline in Section C.
Yes
No
4. Does the device address a health, safety, or welfare issue for this member? Outline in Section C.
Yes
No
5. Does the service plan identify the need for the requested device?
Yes
No
6. Does this device address an ADL or IADL need? Outline in Section C.
Section C Narrative Description Justifying Request
Provide specific information and use additional sheet if necessary. Provide the cost of items that are $50 or under.
IMPORTANT NOTE: In evaluating requests for prior authorization,
Requesting Case Manager
the need for treatment or services will be considered from the
Signature of TCM/CM/SW
Date
standpoint of medical necessity only. An approval of this request
does not indicate that the member continues to be eligible for Medicaid.
It is the responsibility of the provider who initiates the request for prior
authorization to establish eligibility at the time of service.
Section D Include ALL of the Following Documentation
Comprehensive functional assessment
Case manager or social worker service plan
Three independent itemized estimates (if over $50)
Documented description of the item that includes the direct medical, remedial, or safety benefit to the member
Denial from state plan durable medical equipment, if applicable

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