Fillable DME Pre-Authorization Request Form

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DME Pre-Authorization Request Form

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The DME Pre-Authorization Request Form form is 1 page long and contains:

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  • 30 other fields

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File type: PDF

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1603 Lyndon B Johnson Fwy Suite 300,
Farmers Branch, TX 75234
cnchealthplan.com
DME Pre-Authorization Request Form
Phone: 855-359-9999 Fax: 888-965-1964
Patient’s Name: Birth Date:
Member ID#:
DME Provider: DME NPI:
DME Contact Person:
DME Phone: DME Fax:
Requesting Physician: NPI:
PCP: NPI:
Proposed Date of Service:
RENTAL PURCHASE
ICD-10 CM Diagnosis Description ICD-10 CM Code
Procedure: CPT/HCPCS Exact Description (one per line please) CPT/HCPC Code (one per line please)
Describe any special circumstances which should be considered when authorizing services:
Clinical Information/Comments: (You may attach clinical)
This request will be treated as per the standard organization determination timeframes. If the request needs to be treated as expedited, clinical
justification must be provided that applying the standard time for making a determination could seriously jeopardize the life or health of the member or
the member’s ability to regain maximum function:
Authorization does not guarantee or confirm benefits will be paid. Payment of claims is subject to eligibility, contractual limitation, provisions and exclusions.
Health Plan/Payor: Today’s Date:_______________
□ Care N’ Care PPO □ Care N’ Care HMO
cnchealthplan.com
CNC120321
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DME Pre-Authorization Request Form

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Completed 24 February 2022

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