Member Information and Clinical Justification Form for DME Requests
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria
Documentation-based coverage determination
Covered when ALL required documentation is provided and attested:
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 Code | Field label for diagnosis code(s) to be entered |
Provider Actions and Submission Requirements
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)
(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
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)
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
Medical Necessity Requirements
Clinician attestation requirement
Medical necessity determination relies on the clinician-completed assessment documenting relevance to diagnosis and need for requested items.
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
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.
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