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Diabetic_Shoe_Form_Update_2021.pdfDiabetic Shoes Form
Diabetic Shoes Form
Diabetic Shoes may be covered annually for many insurances. In order to qualify, these attached forms must be completed and submitted to us with signed CHART NOTES to show the medical necessity of Diabetic Shoes.
Diabetic Shoes must be prescribed with Diabetic Inserts to dispense.
Maternity Order Form.pdfMaternity Order Form
Maternity Order Form
Breast Pump covered through insurance form
Not all insurance reimburse the same rate which why all american medical supply carries a variety of insurance covered breasts pumps. * remember all pump are final sale and can not be return for hygiene concerns. You will contact the manufacture directly for replacement or warranty ( included in your starter sets). Most warranty is applicable for up to 3 months from the date you dispensed the pump .
Medicaid / MCO: covers the following models watch the video to help you decide which pump is best for you:
Manual Wheelchair_Dear Doctor (1).pdfManual Wheelchair -How to Order
Manual Wheelchair -How to Order
Drive-Group_1_x_Group_2_Medicare_Eligibility_Flowchart.pdfHospital Bed & Mattress Form
Hospital Bed & Mattress Form
Reference Chart will guide providers when prescribing support surfaces seeking insurance coverage
Support surfaces are covered with a hospital bed received through insurance. and only work with hospital beds
Requirements for all american medical supply to process orders:
Detailed Prescription - Name of Patient, DOB, Name of item, length of need, supportive diagnosis, Provider Signature & NPI & date of signature
Chart Notes to justify the medical necessity of Support Surface to be used with a Hospital bed
Prior authorization form depending on insurance carrier. ** Commercial insurances ( i.e Blue Cross Blue Shield of IL) do not need a form unless stated by all american medical supply
Medicare Beneficiaries use CMS DMERC 01.02B
Illinois Medicaid, County Care, Meridian , Aetna or Blue Cross Blue Shield MMCP of Illinois use HFS 2305a for Air Fluidized and HFS 3701g for decubitus mattress .
Hospital Bed prior authorization form for Medicaid of Illinois and MCO plans
Hospital Bed prior authorization form for Medicaid of Illinois and MCO plans
Make sure to provide a detailed prescription for a Semi Electric Hospital Bed with the above form to process an order for Hospital beds under Medicaid of Illinois and MCO plans.
hfs3701k_Pmd.pdfPower Wheelchair-Medicaid and MCO plans
Power Wheelchair-Medicaid and MCO plans
Detailed Prescription with pertaining diagnosis
Physician's Form( State Medicaid) -available to the left
Chart Notes to show the patient's concerns with mobility inside and outside the home.
** Prior Authorization is needed for this item allow 10 to 30 for processing by your insurance after all items have been faxed in
Face to Face documentation guidelines below for prescribing Providers
Face to Face documentation guidelines below for prescribing Providers
Power Wheelchair
Face to Face must be complete with you doctor's to chose the medical necessity over the use of a manual wheelchair
An in-person visit between the ordering physician and the beneficiary must occur. This visit must document the decision to prescribe a PMD.
A medical evaluation must be performed by the ordering physician. The evaluation must clearly document the patient's functional status with attention to conditions affecting the beneficiary's mobility and their ability to perform activities of daily living within the home. This may be done all or in part by the ordering physician. If all or some of the medical examination is completed by another medical professional, the ordering physician must sign off on the report and incorporate it into their records.
Items 1 and 2 together are referred to as the face-to-face exam. Only after the face-to-face examination is completed may the prescribing physician write the prescription for a PMD. This prescription has seven required elements and is referred to as the seven-element order which must be entered on the prescription only by the physician.
Attached PRIOR AUTHORIZATION form must be faxed to provider with chart notes and prescription. Chart notes should show consideration as to what other items of mobility assistive equipment (MAE), e.g., canes, walkers, manual wheelchair, etc., might be used to resolve the beneficiaries mobility deficits. Information addressing MAE alternatives must be included in the face-to-face medical evaluation.
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