CurrentAlaska MedicaidPolicy N/A

Member Information and Clinical Justification Form for DME Requests

This document is a fillable member information and clinical assessment form used to request durable medical equipment (DME) services from Alaska Medicaid; it governs what patient, provider, and clinical justification details must be supplied and who may complete sections.

Policy Summary

PayerAlaska Medicaid

PolicyMember Information and Clinical Justification Form for DME Requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must supply prescriber and provider identifiers, member demographics, diagnosis codes and descriptions, prescription start date, estimated length of need, and a clinician-completed Section C attesting to medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4diagnosis/description entry lines provided

1-99Estimated length of need field

Section CClinical assessment section

RequiredProvider attestation

Coverage Criteria

Documentation-based coverage determination

Covered when ALL required documentation is provided and attested:

Form completion and attestation: Provider and member identification fields completed; diagnosis code and description provided; prescription start date and estimated length of need provided; Section C clinical assessment documents medical necessity and lists each service or item needed; form signed by ordering provider or specialist.

Supporting documentation may be attached as needed.

No information in the sections specifically designated in this form may be completed by the DME supplier. Fields such as Date of last visit related to request, Diagnosis Code and Description, Prescription Start Date, and Est. Length of Need (1-99 months, 99 = lifetime) must be completed by the ordering provider or authorized clinician, not the supplying vendor.

Coding and Duration

Diagnosis entry fieldsICD-10

Diagnosis Code

Field label for diagnosis code(s) to be entered

Policy Summary

PayerAlaska Medicaid

PolicyMember Information and Clinical Justification Form for DME Requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Estimated length of need1-99 months (use 99 to indicate lifetime)

Entry formatSingle numeric entry on form next to 'Est. Length of Need'

Use for authorization periodRepresents the requested duration for the prescription start date through estimated need period

Provider Actions and Submission Requirements

Prior Authorization

Authorization information to submit

Include the following information when submitting an authorization request. Complete and accurate fields speed review and reduce denials.

Diagnosis codes (ICD-10) and description
Prescription start date and estimated length of need (months; use 99 = lifetime)
Member demographics: name, Medicaid ID, DOB, gender, height, weight, phone
Prescriber/provider identifiers: Prescriber name, Provider Medicaid ID or NPI, phone, fax
Date of last visit related to the request
Detailed medical justification / clinical assessment (see Section C) and plan of care
Attach supporting documentation (progress notes, specialist assessments, test results, prior treatments)

Documentation Required

(Provider action) Submission responsibilities

Providers must complete their portion of the form and ensure suppliers do not fill sections restricted to prescribers. Signatures and required fields must be present to avoid processing delays.

Member information (demographics and contact) must be provided by the ordering prescriber
Supplier must not complete prescriber-specific sections
Date of last visit related to the request must be included

Documentation Required

Required form fields and attachments

Required form fields and attachments must be submitted with the authorization request. Incomplete submissions may be returned or denied.

Prescriber/provider identifiers: Prescriber Name, Provider Medicaid ID or NPI, phone, fax
Member demographics: Member Name, Member Medicaid ID, DOB, gender, height, weight, phone
Clinical sections: Diagnosis code(s) and description, Prescription start date, Estimated length of need
Section C: Clinical assessment of need and specific plan of care (can be completed by attending specialist within scope)
Attachments: supporting documentation (progress notes, specialist evaluations, test results, prior authorization history)

Denial Risk

Fraud / False statement risk

False statements, omissions, or concealment of material facts on this form may subject the attesting clinician to civil and criminal penalties under federal and state law.

Attestation language: By signing, the clinician certifies that the medical necessity information is true, accurate, and complete
Consequences: Civil monetary penalties, fines, and criminal prosecution may result from falsification or omission
Signature requirement: The ordering physician/physician assistant/nurse practitioner/audiologist (or specialist when Section C is completed by a specialist) must sign and date the form

Background

Section C — Clinical Assessment of Need for Prescribed Service(s) or Item(s) and Plan — is intended for the attending specialist or ordering clinician to annotate the medical justification that directly relates to the member’s diagnosis and the items or services requested. The section must document the clinical rationale and include an explicit plan listing each service or item needed; supporting treatment information may be attached as necessary.

Definitions

Specialist definitions

Authorized specialist types (examples)PT (Physical Therapist), OT (Occupational Therapist), SLP (Speech-Language Pathologist), RD (Registered Dietitian)

Prescribing and attesting cliniciansMD (Physician), NP (Nurse Practitioner), PA (Physician Assistant), Audiologist

Other permitted specialistsPhD, LSW and other attending specialists within scope

Signature requirementSection C must be signed by the specialist when completed by someone other than the ordering provider

Medical Necessity Requirements

Clinician attestation requirement

Medical necessity determination relies on the clinician-completed assessment documenting relevance to diagnosis and need for requested items.

Clinician attestation: A licensed clinician within scope must attest that requested items are medically necessary for the patient listed; falsification may incur penalties.

Section C may be completed by the attending specialist (physician, PA, NP, PT, OT, SLP, RD, audiologist, or other attending specialist) and must be signed by the specialist if completed by someone other than the ordering provider.

Documentation Requirements

Documentation Required

Clinician assessment and attestation required in Section C

Section C must include a clinician's assessment that documents medical justification specific to the member’s diagnosis and lists each service or item needed; the assessment must be signed by the attesting clinician.

Clinical justification tied to the member's specific diagnosis
Plan listing each service or item specifically needed
Signature, title, and date of the attesting clinician (specialist or ordering provider)

Not Covered / Supplier Restrictions

Sections that are explicitly designated on the form as not to be completed by the DME supplier are excluded from supplier completion. The form lists examples of such fields — including Date of last visit related to request, Diagnosis Code/Description, Prescription Start Date, and Est. Length of Need (1-99 months, 99 = lifetime) — which must be completed and attested by the ordering provider or authorized clinician.