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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 ACCESS
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