Fillable DME Authorization Refer to the back of the (GEHA)

Fill Online, Printable, Fillable, Blank DME Authorization Refer to the back of the (GEHA) Form

Use Fill to complete blank online GEHA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

DME Authorization Refer to the back of the (GEHA)

On average this form takes 8 minutes to complete

The DME Authorization Refer to the back of the (GEHA) form is 2 pages long and contains:

  • 0 signatures
  • 11 check-boxes
  • 27 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your GEHA forms online.

BROWSE GEHA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Revised 122921 CM-FRM-0118-003
DME Authorization
Refer to the back of the patient’s ID card under the heading Prior Authorization for the
appropriate contact information.
Purpose of this form
You can use this form to initiate your precertification request. The form will also help you
know what supporting documentation is needed for GEHA to review your request.
You can find our coverage policies at Provider resources. These will allow you to see the
criteria used to determine medical necessity and procedures that are not allowable.
For us to review your request properly and to avoid delay, you must complete all sections of
the form and provide the necessary supporting documentation. If you have questions about
the form or need help, you can speak with a surgical specialist at 800.821.6136, ext. 3100.
After you have completed the form
Preauthorization reviews are completed within 15 days from the time that we receive
complete information. Please allow for this time when scheduling the procedure. We are not
able to consider a request “urgent” unless waiting the regular time limit for authorization could
seriously jeopardize a patient’s life, health or ability to regain maximum function. Post-service
reviews are completed within 30 days.
Revised 122921 CM-FRM-0118-003
DME Authorization
Date of request:
Patient name: Phone:
ID number: Date of birth:
Member address:
DX: ICD-10 code:
Billing provider information
Provider name:
Tax ID:
Address:
Contact:
Phone: Fax:
Prescribing physician: NPI:
Items not covered under the plan:
• Computers, tablets, computer programs/games used in association with communication aides,
internet or phone services used in conjunction with communication devices.
• Air purifiers, air conditioners, heating pads, cold therapy units, whirlpool bathing equipment,
sun and heat lamps, exercise devices (even if ordered by a doctor), and other equipment that
does not meet the definition of durable medical equipment.
• Lifts, such as seat, chair or van lifts.
• Wigs
• Devices or programs to eliminate bed wetting
• If a member is a patient in a facility other than the member's primary residence, or in a distinct
part of a facility that provides services such as skilled nursing, rehabilitation services, or
provides medical or nursing, DME will not be covered separately for rental or purchase.
Preauthorization (covered items under the plan)
Manual wheelchair
Electric wheelchair
Scooter
Prosthetic
Oxygen (Desat level: ________)
Continuous Glucose Monitoring System
BIPAP
CPAP/APAP and supplies
Oral appliance
Assistive Communication Device (ACD)
Other
HCPCS codes: DME list price:
Description of equipment – manufacture/maker of equipment:
Treatment start date: Length of need: ____ days ____ months ____ years
(date equipment is placed)
Revised 122921 CM-FRM-0118-003
Attach the following documentation:
• Letter of medical necessity and/or physician’s orders
• Documentation of patient’s general condition, including upper and lower body strength and
activity level
• Documentation of patient status (i.e., bed confined, chair confined, ambulatory, orientation,
orthopedic impairment, etc.)
• For CPAP sleep study and compliance report after 61
st
day of use
• For CPAP/BIPAP Supplies - specific codes are required with request
• For BIPAP, reason as to why patient is not tolerating the CPAP
• For CGMS, most recent history and physical, most current A1C level, results of 72 hour
continuous glucose monitoring test
• For Oxygen, saturation rate
• Any other additional information pertinent to your request
• Cranial helmets require color photos for review
• For CPM, provide the CPT code of the surgical procedure that relates to this request
Review of this service is pending the completion of this form. Incomplete forms will be
returned; attach additional pages as needed. To avoid delay in processing your request,
please provide all information requested.
IMPORTANT: Fax completed form and required documents to 816.257.3515 or 816.257.3255
Questions: Call Care Management at 800.821.6136, Ext. 3100.
Payable benefits are subject to the terms and conditions of the Health Benefit Plan.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

DME Authorization Refer to the back of the (GEHA)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 February 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document