Certificate Of Medical Necessity For Home And Vehicle Modification Template
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1Iowa Medicaid Enterprise
Certificate of Medical Necessity for
Home and Vehicle Modification
Use this form as your cover page. Fax to Medical Services Waiver Prior Authorization 515-725-1388.
(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:
Remember to attach all documentation.
7. Type of Review Being Requested:
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 13 for Home and Vehicle Modification
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 modification covered by other funding sources? Outline in Section C.
Yes
No
3. Is this an existing structure? If yes, provide detailed information in Section C.
Yes
No
4. If this is an existing structure, can it be repaired? Describe in Section C.
Yes
No
5. Is this modification for the sole benefit of the member? Describe benefit to member in Section C.
Yes
No
6. Are any of the contractors related to the member? If yes, provide relationship in Section C.
Yes
No
7. Will this modification increase or maintain the independence of the member? If yes, outline in Section C.
Yes
No
8. Does this modification address a health, safety, or welfare issue for this member? Outline in Section C.
Yes
No
9. Does the service plan indentify the need for requested modification?
10. Will the case manager obtain assurance of liability and workers compensation coverage from
Yes
No
contractor?
Yes
No
11. To the best of case manager’s knowledge, are the contractors submitted for review reputable?
Yes
No
12.
Outline details in Section C.
If vehicle modification, is the primary vehicle used by the member?
13. Does the member or member’s family
Yes
No
Own
Live in provider-owned home
Rent
Live in HUD housing
Section C Narrative Description Justification 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, the
Requesting Case Manager
need for treatment or services will be considered from the standpoint of
Signature of TCM/CM/SW
Date
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
Denial for state plan durable medical equipment, if applicable
•
•
Case manager or social worker service plan
If existing item, need repair versus replacement cost estimate
•
Documented description of the item that includes the medical, remedial, or safety benefit to the member
•
Three independent itemized estimates (if over $50)
470-5050 (8/11)
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