Investor Presentaiton
DEPARTMENT OF VERMONT HEALTH ACCESS
VERMONT MEDICAID MEDICAL NECESSITY FORM (MNF), GENERAL
(EXAMPLE - ORTHOTICS, PROSTHETICS, MEDICAL SUPPLIES &
DURABLE MEDICAL EQUIPMENT
All claims for supplies and equipment require a written order. Orders must be signed by a physician, physician assistant, or nurse practitioner. All
home health plans of care require a physician signature. Copies of the order must be kept in the patient record by both the ordering provider and
Durable Medical Equipment (DME) supplier. It is the responsibility of the ordering provider to complete or review this Medical Necessity Form (MNF)
and provide adequate documentation supporting the medical need for the items listed. The ordering provider must provide this documentation either
for the Medicaid beneficiary to take to the DME supplier of choice or directly to the DME supplier The DME supplier must be enrolled in Vermont
Medicaid. The ordering provider must document a description of the device and/or its HCPCS code. If the ordering provider does not provide the
HCPCS code, the DME supplier must provide the HCPCS code for all prior authorizations and on all claims, on this form or on other documentation
submitted to the DVHA and DXC. The codes submitted to DVHA and DXC must match the description documented by the ordering provider.
All orders must adhere to state and federal rules and regulations. Vermont Medicaid Rules can be found online at
http://humanservices.vermont.gov/on-line-rules.
DME
16
Section A: (must be completed or reviewed and signed by ordering provider)
1. Beneficiary's name: Jane Doe Medicaid ID#: 123456
2. Diagnoses: 110 Essential (primary) hypertension
3. Place of service: Home
Is the beneficiary living in a skilled nursing facility? Yes
No
Is the request part of a home health plan of care? Yes
Description
Modifier
Medical Necessity of Item
No
Expected Length
of Need (months)
# Per Month
Code
A4670
Automatic blood pressure
monitor
N/A
HTN
99
1 purchase
4.
HCPCs
The HCPCS code(s) may be provided by the supplying provider when the ordering provider has included a clear
description of the required item(s).
I CERTIFY THAT THE ITEM(S) PRESCRIBED ABOVE IS(ARE) A MEDICALLY NECESSARY PART OF THE
COURSE OF TREATMENT AND NOT FOR CONVENIENCE, COMFORT, OR PRECAUTIONARY PURPOSES
5. Ordering provider's name & address:
6. Ordering provider's signature:
7. Ordering provider's Medicaid provider #:
Date signed:
Phone#:
See back of form for DME information and instructions
The ordering provider must document a
description of the device and/or its
HCPCS code.
If the ordering provider does not provide
the HCPCS code, the DME supplier must
provide the HCPCS code for all prior
authorizations and on all claims, on this
form or on other documentation
submitted to the DVHA and DXC.
The codes submitted to DVHA and DXC
must match the description documented
by the ordering provider.
VERMONT
AGENCY OF HUMAN SERVICES
DEPARTMENT OF VERMONT HEALTH ACCESSView entire presentation