Durable Medical Equipment/Supplies (DME)
Prior Authorization Request Form
The form may be submitted without the prescribing providers' signature and date; however, one of the following must be submitted with the request:
a si
gned and dated prescription, a dated written order, or a dated documented verbal order.
DME Auth Req form 050219 RevOct-19
General Instructions:
Effective August 1, 2019, all providers requesting Durable Medical Equipment (DME) and Medical Supply Prior Authorization services
for Cook Children’s Health Plan members may use the CCHP Durable Medical Equipment/Supplies (DME) Prior Authorization Form
or current Standardized Prior Authorization form. This form may be used for members of all ages, for initial authorization requests, and
for all subsequent recertification requests in lieu of the Title XIX form. Prior Authorization requests may be submitted by fax or via
CCHP Secure Provider Portal
Providers must submit required documentation demonstrating medical necessity, and obtain necessary orders and signatures, as
outlined in the Texas Medicaid Providers Procedures Manual (TMPPM) for the requested service. Providers must submit
recertification requests no earlier than 30 days before the current authorization period expires.
Directions for completing the Durable Medical Equipment/Supplies (DME) Prior
Autho
rization Form:
Enter the member’s name i
Enter member’s ICD-10 Code(s) and diagnoses for the medical conditions that require authorization of services.
Requested
Enter the place of service requested as appropriate to provider type.
Please indicate if the request is routine or urgent. Please note, if the member is discharging from an inpatient
hospital, urgent may be selected to prevent a delay in member discharge.
Request marked as urgent that are not will be processed by CCHP as a routine request.
Service Code and
Modifier
Dates of Service: From
& Through
On the line for each service code requested enter the requested service dates:
“The From” date should be the date requested services are to be initiated.
“The Through” date should be the last date the requested services are to be requested.
Enter applicable modifier (s) for the requested service code.
Total Number of Units
Requested
Calculate and enter the total number units requested for the authorization period that is being requested.
Indicate unit with each requested service code.
Service Code
Description
Enter the description of the service code (s) being requested
Cost Enter all charges that will be billed to CCHP
Prescribing Provider,
Printed Name,
Signature, Date
If the prescribing provider is signing the form, the provider must print, sign and date the form. The form may be
submitted without the prescribing provider’s signature and date, but the form must be accompanied by a signed
and dated written order, prescription, or documented verbal order and include frequency and duration of services.
All verbal orders must be co-signed by practitioners that include verbal orders within their scope of practice.
Prescribing Provider
NPI and License No.
Enter the prescribing provider’s NPI and License Number
Date client last seen
by prescribing
provider
Enter the date the client was last seen by the prescribing provider.
Servicing Provider
Information
This section is for the provider or agency who is billing for the requested services.
Name, Telephone,
Address, Fax, TPI, NPI
Enter the contact information for the provider or agency. The telephone and fax number will be used by CCHP
for authorization approvals or to request additional information. The address should be the same as the one
associated with the provider’s NPI or TPI.
Taxonomy and Benefit
Code
Providers need to enter taxonomy code and benefit code information if they do not enter their TPI on the form
and they have multiple physical locations or program enrollments under the same NPI.
