Title Xix Form PDF Details

The intricacies of medical billing and the provision of home health services are encapsulated within the framework of the Title XIX Form, a crucial document for healthcare providers and recipients under the Medicaid program. This form serves as a physician order form for Home Health Durable Medical Equipment (DME) and Medical Supplies, marking a pivotal step in securing necessary healthcare items for patients in need. The essence of the form lies in its dual purpose: firstly, to request essential DME and medical supplies deemed necessary for patient care, and secondly, to act as a vehicle for prior authorization to ensure these requests meet the stringent criteria set forth by Medicaid. A unique aspect of this form is the binding certification by both the Provider and the Prior Authorization Request Submitter, affirming the accuracy, comprehensiveness, and veracity of the submitted information under penalty of perjury. They acknowledge that payment of claims is contingent upon prior authorization, reinforcing the principle that this procedural step is not merely administrative but a gatekeeping measure to ensure the judicious use of Medicaid funds. The form meticulously details the necessary client and supplier information, alongside a structured section for delineating the specific DME and medical supplies requested, each subject to rigorous scrutiny for medical necessity and appropriateness for home use. By emphasizing the role of the physician in certifying the need and appropriateness of the requested items, the form underscores the critical interface between medical judgment and administrative oversight, embedding checks and balances within the process of care provision. The detailed attestations and certifications articulate a clear message: beyond facilitating access to essential healthcare services, the Title XIX Form embodies a commitment to integrity, accountability, and the responsible stewardship of public health resources.

QuestionAnswer
Form NameTitle Xix Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesHome Health Title XIX Supplies Order Form title xix form 2013

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Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form

See instructions for completing Title XIX Home Health Durable Medical Equipment (DME)/Medical Supplies Physician Order Form. This order form cannot

be accepted beyond 90 days from the date of the physician's signature.

Prior Authorization Request Submitter Certification Statement

I certify and affirm that I am either the Provider, or have been specifically authorized by the Provider (hereinafter "Prior Authorization Request Submitter") to submit this prior authorization request.

The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that they are personally acquainted with the information supplied on the prior authorization form and any attachments or accompanying information and that it constitutes true, correct, complete and accurate information; does not contain any misrepresentations; and does not fail to include any information that might be deemed relevant or pertinent to the decision on which a prior authorization for payment would be made.

The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that the information supplied on the prior authorization form and any attachments or accompanying information was made by a person with knowledge of the act, event, condition, opinion, or diagnosis recorded; is kept in the ordinary course of business of the Provider; is the original or an exact duplicate of the original; and is maintained in the individual patient's medical record in accordance with the TEXAS MEDICAID PROVIDER PROCEDURES MANUAL (TMPPM).

The Provider and Prior Authorization Request Submitter certify and affirm that they understand and agree that prior authorization is a condition of reimbursement and is not a guarantee of payment.

The Provider and Prior Authorization Request Submitter understand that payment of claims related to this prior authorization will be from Federal and State funds, and that any false claims, statements or documents, concealment of a material fact, or omitting relevant or pertinent information may constitute fraud and may be prosecuted under applicable federal and/or State laws. The Provider and Prior Authorization Request Submitter understand and agree that failure to provide true and accurate information, omit information, or provide notice of changes to the information previously provided may result in termination of the provider’s Medicaid enrollment and/or personal exclusion from Texas Medicaid.

The Provider and Prior Authorization Request Submitter certify, affirm and agree that by checking "We Agree" that they have read and understand the Prior Authorization Agreement requirements as stated in the relevant Texas Medicaid Provider Procedures Manual and they agree and consent to the Certification above and to the Texas Medicaid & Healthcare Partnership (TMHP) Terms and Conditions.

□We Agree

F00030

Page 1 of 2

Revised Date: 02/01/2016 | Effective Date: 04/01/2016

Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form

See instructions for completing Title XIX Home Health Durable Medical Equipment (DME)/Medical Supplies Physician Order Form. This order form cannot be

accepted beyond 90 days from the date of the physician's signature.

Section A: Requested Durable Medical Equipment and Supplies

□ Supplier

This section was completed by (check one): □ Requesting Physician

Client Information

Client Name:

Medicaid number:

Date of birth:

 

 

 

Supplier Information

 

 

 

 

Name:

 

 

Telephone:

 

Fax number:

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

TPI:

NPI:

Taxonomy:

Benefit Code:

 

 

 

 

 

 

 

 

QRP name:

 

QRP TPI:

QRP NPI:

 

 

 

 

 

 

 

 

 

I certify that the services being supplied under this order are consistent with the physician's determination of medical necessity and prescription. The prescribed items are appropriate and can safely be used in the client’s home when used as prescribed.

DME/medical supplies provider representative signature:

Date:

DME/medical supplies provider representative name (Typed or Printed):

Prescribing Physician Information

Name:

Telephone:

Fax number:

Item

HCPCS

Description of

Qty.

Price

Prior

Beyond

Custom

Number

Code

DME/medical supplies

 

 

authorization

quantity

item?1

 

 

 

 

 

required?

limit?1

 

1

 

 

 

 

□ Y □ N

□ Y □ N

□ Y □ N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

□ Y □ N

□ Y □ N

□ Y □ N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

□ Y □ N

□ Y □ N

□ Y □ N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

□ Y □ N

□ Y □ N

□ Y □ N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.If “Yes,” additional documentation must be provided to support determination of medical necessity.

Section B: Diagnosis and Medical Need Information

This is a prescription for DME/supplies and must be filled out by the prescribing physician.

Item

Number2

(From

Section A)

Diagnosis

Brief Diagnosis Descriptor

Complete justification for determination of medical necessity for requested item(s)2

(Refer to Section A, footnote 1)

2.Each item requested in Section A must have a correlating diagnosis and medical necessity justification.

Enter all ITEM NUMBERS from the table in Section A that pertain to each diagnosis. A range of item numbers may be entered.

If applicable, include height/weight, wound stage/dimensions and functional/mobility status:

Note: The "Date last seen" and "Duration of need" items must be filled in.

Date last seen by physician:

Duration of need for DME: ____________ month (s)

Duration of need for supplies: ____________ month (s)

By signing this form, I hereby attest that the information in Section “A”, with the exception of the DME provider's signature, was complete at the time of my signature and is consistent with the determination of the client's current medical necessity and prescription. By prescribing the identified DME and/or medical supplies, I certify the prescribed items are appropriate and can safely be used in the client’s home when used as prescribed.

Signature and attestation of prescribing physician:

Date:

Signature stamps and date stamps are not acceptable

Prescribing physician TPI:

NPI:

License number:

F00030

Page 2 of 2

Revised Date: 02/01/2016 | Effective Date: 04/01/2016

How to Edit Title Xix Form Online for Free

Working with PDF documents online is definitely very easy with this PDF tool. Anyone can fill out Title Xix Form here painlessly. To keep our editor on the cutting edge of efficiency, we strive to integrate user-oriented capabilities and enhancements on a regular basis. We're routinely thankful for any feedback - join us in revolutionizing PDF editing. Here's what you will have to do to get going:

Step 1: Access the PDF doc inside our editor by clicking on the "Get Form Button" at the top of this page.

Step 2: As soon as you launch the editor, you will notice the document all set to be filled in. Apart from filling out various blank fields, you may as well do many other things with the file, such as putting on any text, modifying the initial textual content, adding graphics, placing your signature to the form, and a lot more.

Be attentive when completing this form. Ensure that all necessary areas are done accurately.

1. It's essential to fill out the Title Xix Form properly, therefore take care when filling in the segments including all these blanks:

Filling out section 1 in Title Xix Form

2. The subsequent stage would be to fill out the following fields: Section A Requested Durable, Client Name, Name, Address, TPI, QRP name, Client Information, Medicaid number, Supplier Information, Date of birth, Telephone, Fax number, NPI, Taxonomy, and QRP TPI.

Name, Section A Requested Durable, and NPI inside Title Xix Form

3. Completing Beyond quantity limit, required, Y N Y N Y N Y N Y N Y, If Yes additional documentation, Section B Diagnosis and Medical, Item, Number, From, Section A, Diagnosis, Brief Diagnosis Descriptor, Complete justification for, medical necessity for requested, Refer to Section A footnote, and Each item requested in Section A is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Step no. 3 in filling in Title Xix Form

People generally make errors while filling out Refer to Section A footnote in this part. You need to go over what you enter here.

4. The next section requires your attention in the subsequent places: If applicable include heightweight, Note The Date last seen and, Duration of need for DME month s, Duration of need for supplies, By signing this form I hereby, Signature and attestation of, Date, Prescribing physician TPI, NPI, License number, Signature stamps and date stamps, Page of, and Revised Date Effective Date. Always enter all requested info to go onward.

Title Xix Form writing process explained (portion 4)

Step 3: Proofread all the information you have entered into the form fields and click on the "Done" button. Right after getting afree trial account here, it will be possible to download Title Xix Form or send it via email directly. The PDF file will also be accessible through your personal account with your every single edit. With FormsPal, you can certainly complete forms without needing to worry about data breaches or records being distributed. Our protected system makes sure that your personal details are kept safely.

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