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Information Regarding Use of Title XIX Form for DME Requests

Date: 05/15/19

As a reminder, Superior does not require a Title XIX form to be submitted with DME equipment and supply requests for Medicaid (STAR, STAR Health, STAR Kids and STAR+PLUS) or CHIP.

Providers may continue to use the following forms when submitting a request for DME equipment or supply requests:

Provider documentation must include all federally required information. Required information for a DME request submission includes, but is not limited to:

  • Beneficiary Name
  • Contact Info
  • Date of Birth (DOB)
  • Date of Last MD Visit (must be within the last 6 months)
  • Dates of Service
  • Duration of Need
  • HCPC Code(s)
  • Medicaid ID
  • Physician Order No Older Than 90 Days
  • Quantity per Item
  • Relevant Diagnosis
  • Rendering Provider NPI
  • Rendering Provider TIN
  • Rental or Purchase
  • Servicing Provider NPI
  • Servicing Provider TIN
  • Supporting Clinical Information Appropriate to the Item Being Requested

For questions, please contact your dedicated Account Manager.