Pre Certification Form For External Insulin Pump And Supplies printable pdf download

NEIGHBORHOOD HEALTH PARTNERSHIP

PRE-CERTIFICATION FORM

FOR: External Insulin Pump and Supplies

Fax Requests to 800-731-6984

Please be advised, failure to comply with Utilization Management certification protocol will result in non-payment of your claim.

To avoid any delay of this review, please submit all relevant documentation with this form.

** Please include all pertinent clinical information and laboratory results **

REQUESTING PROVIDER INFORMATION

PATIENT INFORMATION

Patient Name:

Provider Name:

_________________________________________________

__________________________________________________________

ID Number:

Provider ID:

_________________________________________________

__________________________________________________________

Patient Phone Number:

Phone: ____________________ Fax: __________________________

_________________________________________________

Contact Name: _____________________________________________

Patient DOB: _________/______________/______________

❏ PCP Request

❏ Specialist Request

PROCEDURE INFORMATION

CHOOSE ONE PROVIDER FOR THE PUMP AND SUPPLIES

Primary Diagnosis: _________________________________

❏ Minimed Distribution Group

800-933-3322

Secondary Diagnosis:________________________________

❏ Animas Diabetes Care LLC

877-937-7867

Diagnosis Code:____________________________________

Please Check:

❏ Disetronic Medical System

800-280-7801

❏

Pediatric Pump Model ❏

New Insulin Pump

❏ Smiths Medical MD

800-826-9703

❏

Replacement Pump

Reason_______________________________________________

CRITERIA CHECKOFF LIST

❏ Yes ❏ No

1. Has the patient completed a comprehensive diabetes education program?

❏ Yes ❏ No

2. Has the patient been on a program of multiple daily injections of insulin (at least 3 injections per day)?

3. Along with the three daily injections, has the patient had frequent self- adjustments of insulin dose for at least

❏ Yes ❏ No

6 months prior to initiation of the insulin pump?

4. Does the patient have documented frequency of glucose self-testing an average of at least 4 times per day

❏ Yes ❏ No

During the 2 month prior to initiation of the insulin pump?

❏ Yes ❏ No

5. Does the patient have a Glycosylated hemoglobin Level (HbA1C) greater than 7%?

Please include with clinical information any wide fluctuations in blood sugars before mealtime, dawn phenomenon with fasting

blood sugars frequently exceeding 200mg/dl and any history of severe glycemic excursions. (Include lab results with request).

HM-3444-2 2/11

Pre Certification Form For External Insulin Pump And Supplies

Related Articles

Related forms

Related Categories