Ky Dme Form PDF Details

If you’re a healthcare provider or a patient struggling to understand the Kentucky Department of Medicaid’s (KY DMes) documentation and form requirements, rest assured that you are not alone. With many complex procedures and regulations in place, navigating KY DME forms can be quite tricky. Regardless of whether you're trying to obtain an authorization for durable medical equipment such as wheelchairs, oxygen systems or prosthetic corsets, fill out provider enrollment forms, submit claim requests or access other KY DMES online services, understanding the process is essential. In this blog post we'll provide an overview of the different types of KY DMEs forms available along with tips on how to complete them correctly and effectively so you can move forward with your desired action without any unnecessary delays!

QuestionAnswer
Form NameKy Dme Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameskentucky medicaid prior authorization list, ky dme, ky medicaid medical authorization form, kentucky medicaid dme prior authorization

Form Preview Example

Kentucky Medicaid

 

 

 

Durable Medical

Equipment (DME) Prior Authorization Form

ywu

 

 

 

Fax (877) 338-3713

 

 

 

 

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

 

 

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

 

 

 

 

 

 

 

 

 

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

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

No

Transition of Care

 

Yes

No

Continuity of Care

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary ICD-9 Code(s)

 

 

 

 

 

Description/Condition

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

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

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)

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In order to fill out this PDF document, make sure you type in the necessary details in each blank field:

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

A lot of people frequently make errors while completing Please submit supportive clinical in this section. You need to go over everything you enter right here.

4. Completing Fax, Web Address wwwkentuckywellcarecom, ywutronmlkeca, Durable Medical Equipment DME, and Clinical Summary is key in this next stage - you should definitely take the time and be attentive with each and every empty field!

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

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