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Paperwork for medicaid to cover pump 2026
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- Click ‘Get Form’ to open the Certificate of Medical Necessity in our editor.
- Begin by filling in the provider's name, NPI number, and Medicaid Legacy number at the top of the form.
- Enter the consumer's details including their name, sex, date of birth, height, and weight. Specify whether you are requesting a 3-month trial rental or purchase.
- In Section A, complete all fields regarding pertinent diagnoses and check 'Yes' or 'No' for each question related to diabetes management and compliance.
- If applicable, provide explanations for any 'No' responses in the designated area.
- Section B requires documentation of compliance after the trial period. Indicate if the consumer is compliant with pump usage and if there has been an improvement in metabolic control.
- Finally, Section C must be completed by the prescriber. Ensure that they print their name, provide their phone number, sign and date the form within 30 days of service.
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