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DME INITIAL PRECERTIFICATION FORM

DME INITIAL PRECERTIFICATION FORM 2026

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The document is a DME Initial Precertification Form used to request prior authorization for durable medical equipment. It includes sections for vendor information, member details, diagnosis codes, ordering physician information, and requested equipment. The form emphasizes the necessity of complete information for processing and clarifies that precertification does not guarantee payment.

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Click ‘Get Form’ to open the DME INITIAL PRECERTIFICATION FORM in the editor.
Begin by filling out the required fields marked with an asterisk (*). Start with the DME VENDOR and LOCATION, ensuring accurate contact details are provided.
Next, enter MEMBER INFORMATION including the member's last name, first name, middle initial, birthdate, and health plan ID. This information is crucial for processing your request.
Provide details for DIAGNOSIS INFORMATION. Fill in the DIAGNOSIS CODE and DESCRIPTION as needed. If there are multiple diagnoses, use additional codes sheets.
In the REQUESTED EQUIPMENT section, specify the HCPCS/MODIFIER and DESCRIPTION along with the quantity (QTY) of each item requested.
Finally, review all entries for accuracy before submitting. Incomplete forms will be returned unprocessed.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (45 Votes)
2018	4.4 Satisfied (242 Votes)
2015	4.2 Satisfied (70 Votes)
2014	4.4 Satisfied (286 Votes)

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How to get a prior authorization form?

To receive coverage for a medication requiring prior authorization, you can: Ask your healthcare provider to submit the request. Your healthcare provider can submit the request online, by fax or phone by accessing our providers prior authorization information. Submit your own prior authorization request. Find Prior Authorization Guidelines and Forms - Humana Humana pharmacy prior-authorizati Humana pharmacy prior-authorizati

What is prior authorization for DME?

Prior authorization is a process through which a request for provisional affirmation of coverage is submitted for review before a DMEPOS item is furnished to a beneficiary and before a claim is submitted for payment. Prior Authorization Process for Certain Durable Medical Equipment - CMS CMS dmepos downloads dmepos-p CMS dmepos downloads dmepos-p

Does DME require prior authorization?

Durable medical equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics. Preview plans and prices based on your income.