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:
- Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form, found on Texas Medicaid and Healthcare Partnership’s (THMP) website.
- The Superior HealthPlan Request for Prior Authorization Form, found on Superior’s Provider Forms website.
- The Texas Standard Prior Authorization Form, found on Superior’s Provider Forms website.
- Other provider specific forms.
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.