Prior Authorization Request Form DME/O&P Items and Services All durable medical equipment and orthotic and prosthetic items and/or services requiring PRIOR AUTHORIZATION must be faxed (or mailed) to MVP’s corporate Utilization Management Department BEFORE services are rendered. Please complete this form in its entirety and fax this form and all supporting medical documentation (lab results, radiology results, consultation reports, evaluations, office notes, etc.)
ALL MVP MEMBERS
FAX to: 888-452-5947
Mailing address: MVP Health Care (Att: DME Unit) 625 State Street Schenectady, NY 12305
For urgent requests (clinical emergencies, facility discharges), please call the UM DME Unit at 1-800-4526966, then fax all supporting medical documentation for the members records. Member Name: DME/O&P Provider Name:
Date of Birth:
ThermApparel Provider NPI# : 1578001499
TIN: MVP Member ID # :
Requesting Physician : Provider NPI#:
TIN: Address :
81-4689261 Address (Location): 125 Tech Park Dr, #1100 Suite 2130 City: Rochester State: NY Zip Code: 14623 Phone number ( 855 ) 232-7233 Fax number ( )
HCPCS codes E1399
Descriptions Miscellaneous Durable Medical Devices
City: State: Zip Code: Physician's office contact name : Phone number ( ) Fax number ( ) ICD-10 Code(s) (Diagnosis):
Expected Date of Delivery :
Person filling out this form: Crystal R. Mendoza Paulin Contact Number including extension: 855-232-7233
Additional Notes for this request:
*Payment for services/items dispensed will be denied when PRIOR authorization is not obtained. The member may not be billed under these circumstances. Please contact 1-800-452-6966 for DME related questions. The DME Prior Authorization Code list is available at: https://www.mvphealthcare.com/providers/reference-library/#utilization
jrs UM/DME 12/22/2016