Patient Instructins fr Hme Medical Equipment In rder fr ABC Health Care t cmplete the request fr yur prescribed hme medical equipment, we will need the fllwing dcumentatin requirements cmpleted in full and prvided t ur ffice in their entirety. 1. Receive cpy f ABC Health Care Hme Medical Equipment Instructins & Dcumentatin Requirements packet Cmpleted 2. Fill ut the ABC Health Care Patient Infrmatin Recrd dcument Cmpleted Patient Name: ABC Patient ID #: 3. Using the Written Order Requirements dcument, cnfirm yur prescriptin / written rder written by yur physician meets the insurance-driven requirements. If nt, cntact yur prescribing physician fr a new prescriptin / "written rder" r t make the apprpriate changes t yur existing prescriptin Imprtant, please nte - All edits t an existing prescriptin must be initialed and dated by the signing physician. Cmpleted 4. Using the Equipment Dcumentatin Requirements dcument, cnfirm all Insurance-required dcumentatin is included. If nt, cntact yur physician t request the Insurance-required medical dcumentatin. IMPORTANT - Medical dcumentatin written n a prescriptin / "written rder" is nt accepted by Insurance cmpanies. It must be written separately in yur medical recrds and be part f yur medical histry frm yur prescribing physician. Cmpleted 5. Once cmplete, submit all f the fllwing t ABC s DME department. It will be scanned and returned t yu. "Patient Instructin fr Hme Medical Equipment" frm "ABC Health Care Patient Infrmatin Recrd" frm Valid Prescriptin / Written Order Equipment Dcumentatin frm with the accmpanying Medical Recrds / Medical Dcumentatin 6. An ABC Health Care Medicare Quality Assurance assciate will review the rder and dcumentatin within 48 hurs f submissin. If rder and dcumentatin are nt cmplete, the Medicare Quality Assurance assciate will deny the request fr equipment and infrm yu f reasns. If rder and dcumentatin are cmplete, the Medicare Quality Assurance assciate will apprve the request fr equipment and infrm yu f apprval and prcess fr receiving yur equipment. Imprtant, please nte ABC will nly prvide equipment after patient c-payment, deductible, and/r prir balance is cllected. 7. ABC Health Care will file yur medical equipment claim with Medicare fr yu and an Explanatin f Benefits frm CMS will fllw t cnfirm billing is cmplete. ABC Health Care 28 Research Drive, Hamptn, VA 23666 Phne: (757) 826-2600 Fax: (757) 826-9269 www.abc-hc.cm Versin Dated 5/1/2017
Patient Infrmatin Recrd Date: Patient Infrmatin: Last Name: First Name: MI: Date f Birth: SS#: Hme Address: City: State: Zip: Cell phne: Wrk phne: Hme phne: Email: Caregiver / Respnsible Party Infrmatin: Last Name: First Name: MI: Cell phne: Wrk phne: Hme phne: Email: Clinical Infrmatin: Gender: Male Female Height: Weight: Health / Infectin Risk: Yes N If Yes, prvide detail: Primary Care Physician: PCP Address: City: State: Zip: Health Insurance Infrmatin: Primary Insurance Cmpany: Plicy Number: Grup Number: Relatinship t Subscriber: Self Spuse Child Other: Secndary Insurance Cmapny: Plicy Number: Grup Number: Relatinship t Subscriber: Self Spuse Child Other: Tertiary Insurance Cmpany: Plicy Number: Grup Number: Relatinship t Subscriber: Self Spuse Child Other: ABC Health Care 28 Research Drive, Hamptn, VA 23666 Phne: (757) 826-2600 Fax: (757) 826-9269 www.abc-hc.cm Versin Dated 7/1/2016
Written Order Requirements Medicare Example #1 Ambulatry Item Per Medicare and the Affrdable Care Act, a detailed written rder fr DME items must be (A) received befre the delivery f an item can take place and (B) must include the fllwing infrmatin (as shwn in the example belw): 1. Beneficiary's name 2. Physician's name 3. Physician s NPI 4. Date f the rder 5. Detailed descriptin f the item(s) with additinal details, as applicable: a. Detailed descriptin f item(s) t be dispensed (with HCPC cdes, if pssible) b. Quantity t be dispensed c. Frequency f use d. Duratin / Length f need e. Number f refills f. Rute f administratin (primarily nly fr respiratry items) g. Dsage & cncentratin (primarily nly fr respiratry items) 6. Physician signature 7. Physician signature date James S. De, M.D. 2 123 Market Street, Hamptn, VA 23666 Phne: (757) 555-1212 Rbert Jnes 1411 Green Place, Chesapeake, VA 23324 NPI# 1234567890 07/01/2016 05/19/1945 Name: 1 Date: 4 Address: DOB: 3 a Lightweight wheelchair (K0003) with elevated leg rests (K0195), anti-tippers (E0971), seat cushin (E2601) and back cushin (E2611) fr daily ambulatin use. 0 99 mnths 1 5 Refills: e Quantity: b Length f Need: d James S De 07/01/2016 6 Signature f Prescriber: Signature Date: 7 ***IMPORTANT Any / each change made t prescriptin that is already signed, must be initialed and dated by the physician t be accepted by Medicare*** ABC Health Care 28 Research Drive, Hamptn, VA 23666 Phne: (757) 826-2600 Fax: (757) 826-9269 www.abc-hc.cm Versin Dated 7/1/2016
*This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* Equipment Requirements & Check-Off List Rllatrs In rder fr ABC Health Care t cmplete the request fr yur prescribed hme medical equipment, we will need the fllwing dcumentatin requirements cmpleted in full and prvided t ur ffice in their entirety. Standard 2-Wheel (Medicare Prvided) Date f rder Detailed descriptin = Rllatr E0143 flding walker with wheels and Duratin / length f need = 99 mnths NPI n prescriptin that matches rdering physician's signature Dcumentatin within the medical chart frm physician detailing: Patient is incapable f functinal independent ambulatin due t specific diagnsis. Diagnsis (and/r assciated symptm) significantly impairs ability t participate in ne r mre mbility-related activities f daily living (MRADL) in the hme. Withut walker, can nly safely ambulate feet (specify distance) The functinal mbility deficit is nt crrected with a cane but can be sufficiently reslved by use f a walker. Patient is willing and able t safely use the walker fr MRADL's in the hme. Heavy Duty 2-Wheel (Medicare Prvided) Date f rder Detailed descriptin = Rllatr E0149 flding walker with wheels and Duratin / length f need = 99 mnths NPI n prescriptin that matches rdering physician's signature Dcumentatin within the medical chart frm physician detailing: Patient is incapable f functinal independent ambulatin due t specific diagnsis. Diagnsis (and/r assciated symptm) significantly impairs ability t participate in ne r mre mbility-related activities f daily living (MRADL) in the hme. Withut walker, can nly safely ambulate feet (specify distance) The functinal mbility deficit is nt crrected with a cane but can be sufficiently reslved by use f a walker. Patient is willing and able t safely use the walker fr MRADL's in the hme. Patient weight was (enter weight; must be ver 300 lbs) punds n (specify date; must be within ne mnth f receipt f walker). ABC Health Care 28 Research Drive, Hamptn, VA 23666 Phne: (757) 826-2600 Fax: (757) 826-9269 www.abc-hc.cm Page 1 Versin Dated 7/1/2016
*This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* Deluxe 4-Wheel w/ Brakes & Basket (This is an upgrade frm the Medicare-Prvided 2-wheeled Mdel) Date f rder Detailed descriptin = Rllatr E0143 flding walker with wheels and Duratin / length f need = 99 mnths NPI n prescriptin that matches rdering physician's signature Dcumentatin within the medical chart frm physician detailing: Patient is incapable f functinal independent ambulatin due t specific diagnsis. Diagnsis (and/r assciated symptm) significantly impairs ability t participate in ne r mre mbility-related activities f daily living (MRADL) in the hme. Withut walker, can nly safely ambulate feet (specify distance) The functinal mbility deficit is nt crrected with a cane but can be sufficiently reslved by use f a walker. Patient is willing and able t safely use the walker fr MRADL's in the hme. In additin t any c-pays r deductibles, the patient is respnsible t pay a fee f $40.00 fr the upgraded mdel that included 2 additinal wheels, handbrakes, and basket. Rllatr Supreme and Custm Mdels ABC can prvide additinal mdels f Rllatr t meet all patient needs and wants including custm features, clrs, wraps, and designs. These additinal features are nt cvered by Medicare and will be quted fr each patient. ABC will bill the Medicare fr the standard mdel and will require the patient be respnsible fr the additinal csts required fr their rder. Detailed Descriptin Infrmatin & Criteria Includes HCPC cdes, prduct descriptins fr all bases, attachments, and miscellaneus parts all as defined by Medicare regulatins: Cde Detailed Descriptin Additinal Criteria E0143 E0147 E0149 WALKER, FOLDING, WHEELED, ADJUSTABLE OR FIXED HEIGHT WALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE WALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE As defined abve Unable t use a standard walker due t a severe neurlgic disrder r ther cnditin causing the restricted use f ne hand Must weigh mre than 300 lbs. E0156 SEAT ATTACHMENT, WALKER Allwed nly if patient meets walker requirements E0158 LEG EXTENSIONS FOR WALKER Patient height must be 6 feet r taller E0159 BRAKE ATTACHMENT FOR WHEELED WALKER, REPLACEMENT ONLY, EACH Allwed nly if patient meets walker requirements ABC Health Care 28 Research Drive, Hamptn, VA 23666 Phne: (757) 826-2600 Fax: (757) 826-9269 www.abc-hc.cm Page 2 Versin Dated 7/1/2016