NC Medicaid Direct uses form 372-131 as a combined certificate of medical necessity and prior approval request for durable medical equipment, orthotics, prosthetics and supplies. Prescribers meet it when a DME supplier sends it for medical and functional details and a signature. It lists up to 10 items with HCPCS codes, new, used or rental status and dates, and supports the supplier's prior approval request.
The DME provider completes the recipient, provider and equipment lines and signs as requesting provider. A physician, physician assistant or nurse practitioner certifies medical necessity and signs; items 19 to 30 describe the patient's medical and functional status.
Download the current version from the source each time; forms change without notice.
NC Medicaid Request for Prior Approval CMN/PA
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Two people sign: the requesting provider, usually the DME supplier, and a physician, physician assistant or nurse practitioner who certifies medical necessity. Each signature has its own date line at the bottom of the form.
No. It is used for NC Medicaid Direct. Members in standard plans follow their plan's own prior authorization process and forms. For NC Medicaid Direct, NCTracks lists the 372-131 among the request forms that can be mailed or faxed to start a prior approval request.