Washington Apple Health uses this two-page evaluation when a hospital bed needs authorization. The provider names the bed type requested, from fixed height to extra heavy duty, the diagnoses with ICD-10 codes, hours per day in bed, and why a simpler bed or positioning aids will not meet the client's needs. It is submitted with the HCA prescription form 13-794.
The prescribing practitioner or evaluating therapist completes the clinical questions and signs with name and credentials. Supplier name, phone and billing NPI are also entered in Section 1.
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Hospital Bed Evaluation Form
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The HCA prescription form 13-794 and any supporting documentation. For a fax submission, the General Information for Authorization form 13-835 goes first, then the 13-794, then the completed HCA 13-747 and supporting records. Online submissions go through the ProviderOne Portal.
The form states that caregiver convenience is not considered medically necessary. The provider has to explain why a fixed or adjustable height bed would not meet the client's needs, and the form asks about immediate position changes related to the medical condition and the risk of aspiration.