Ky Dme Form – Fill Out and Use This PDF

The Kentucky Medicaid Durable Medical Equipment (DME) Prior Authorization Form is designed to ensure that necessary medical equipment and supplies are made available to Medicaid members in Kentucky, pending prior approval. This form requires detailed information on the member, prescribing physician, and supplier, along with the necessary medical justification for the requested equipment or services. The goal is to streamline the approval process for medically necessary items, ensuring members receive the care they need without unnecessary delays. Ready to get started? Click the button below to fill out the form.

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Ky Dme Form PDF Details

The Kentucky Medicaid Durable Medical Equipment (DME) Prior Authorization Form serves a critical function in the healthcare delivery system, ensuring that necessary medical equipment and supplies reach those in need through a regulated approval process. This detailed document mandates the submission of comprehensive clinical information and documentation to justify the request for equipment or services, illustrating a thorough review procedure designed to validate the medical necessity of each request. With options for both standard and expedited processing, the form accommodates urgent needs by allowing healthcare providers to certify the importance of swift review to prevent serious jeopardy to the patient's health or their ability to regain maximum function. Beyond the primary request information, the form collects detailed data about the member in need, the ordering physician, and the supplying provider, ensuring all parties are properly identified and authorized to participate in the care process. Notably, it emphasizes that while authorization is a prerequisite for obtaining the requested DME, it does not guarantee payment, which remains subject to member eligibility and specific plan limitations. This approach underscores the necessity of precision in documentation and adherence to policy for successful navigation of the authorization process. Additionally, it clarifies that emergency care does not require prior authorization, aligning with the overarching goal of Medicaid to facilitate timely access to care in critical situations, further substantiated by the clear definition of what constitutes an emergency or urgent care need.

Question	Answer
Form Name	Ky Dme Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	kentucky medicaid prior authorization list, ky dme, ky medicaid medical authorization form, kentucky medicaid dme prior authorization

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Kentucky Medicaid

		Durable Medical	Equipment (DME) Prior Authorization Form		ywu
		Durable Medical	Fax (877) 338-3713		ywu
		Web Address: www.kentucky.wellcare.com

		CHOOSE THE APPROPRIATE REQUEST TYPE
		Requests for prior authorization (with supporting clinical information and documentation) should be sent to the
	Standard Request	Health Plan fourteen (14) days prior to the date the requested services will be performed. If a response has not
		been received within two (2) business days, call (877) 389-9457 to confirm your request has been received.

		By signing below, I certify that applying the standard review time frame may seriously jeopardize the life or health of
	Expedited Request
	Expedited Request	the member or the member’s ability to regain maximum function.



Physician Signature Validating Expedited Request				Date Signed

Initial Request

Additional months needed

Authorization Number

MEMBER INFORMATION

Last Name

Phone

Number

First Name, Middle	Date of Birth
First Name, Middle
Initial
Initial
WellCare ID Number	Other Insurance?	Yes	No

ORDERING PHYSICIAN INFORMATION

Last Name

First Name

NPI Number

WellCare ID

Type

PCP

Specialist

Specialty

Number

Phone

Fax Number

Participating

Yes

Number

Street

City, State

Zip Code

Address

Name of

Office Contact

(If Different)

Requestor

SUPPLYING PROVIDER INFORMATION

Type

Office

Outpatient hospital

Home Health Agency

DME Supplier

Orthotics/Prosthetics Supplier

Facility Name

Facility ID

NPI Number

Number

Phone Number

Fax Number

Hospital Contact

Address

City, State

Zip Code

EQUIPMENT/MEDICAL SUPPLY INORMATION (Indicate N/A if it doesn’t apply to your request)

Participating

Yes

Transition of Care

Yes

Continuity of Care

Yes

Primary ICD-9 Code(s)

Description/Condition

Item/Service Requested

CPT/HCPCS Code(s)

# of Units

Acquisition Costs			Date(s) of Service
(per unit)			(Start – End)

Please submit supportive clinical documentation to substantiate the need for the proposed equipment /item or service including but not limited to: office notes, hearing evaluations, laboratory and imaging results and skilled therapy reports.

Authorizations will be given for medically necessary services only; it is not a guarantee of payment. Payment is subject to verification of member eligibility and to the limitations and exclusions of the member’s contract. Emergency care does not require prior authorization. An emergency is a medical condition that that manifests itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson, who possesses and average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.*Urgent care is defined as medically necessary treatment for an injury, illness or type of condition (usually not life threatening) which should be treated within 24 hours. (Effective November 1, 2011)

Durable Medical Equipment (DME) Prior Authorization Form ywu Fax (877) 338-3713

Kentucky Medicaid

Web Address: www.kentucky.wellcare.com

Clinical Summary

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1. It's essential to fill out the ky dme authorization properly, thus be attentive while working with the segments comprising these specific blank fields:

ky medicaid medical authorization form conclusion process shown (part 1)

2. Soon after performing the last section, go on to the next part and fill out the essential details in these blanks - Street Address Name of Requestor, Type, Office, Facility Name, Outpatient hospital, SUPPLYING PROVIDER INFORMATION DME, Home Health Agency Facility ID, OrthoticsProsthetics Supplier, NPI Number, Phone Number Address, Zip Code EQUIPMENTMEDICAL SUPPLY, Fax Number City State, Hospital Contact, Participating, and Primary ICD Codes.

Part no. 2 in completing ky medicaid medical authorization form

3. The following step is focused on Please submit supportive clinical, and Authorizations will be given for - type in each one of these blank fields.

Please submit supportive clinical, Please submit supportive clinical, and Authorizations will be given for of ky medicaid medical authorization form

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Web Address wwwkentuckywellcarecom, Fax, and Clinical Summary inside ky medicaid medical authorization form

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Ky Dme Form – Fill Out and Use This PDF

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