Kansas Medicaid (KMAP) uses this one-page form as the prescription and medical necessity statement for blood glucose testing supplies. The physician, ARNP or PA checks the diabetes ICD-10 code, orders a testing frequency and length of need, records insulin use, and explains why more frequent testing is needed and how the results will be used.
The prescribing physician, ARNP or PA completes and signs the whole form, adding the physician's Kansas Medicaid provider ID and NPI. The DME provider completes a separate prior authorization request with the HCPCS codes and modifiers.
Download the current version from the source each time; forms change without notice.
Physician Order Form/Medical Necessity for Diabetes Testing Supplies
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Yes. The form states that it suffices as a script for blood glucose testing supplies. KMAP will not consider it on its own, though: the DME provider must also submit a prior authorization request form with the appropriate HCPCS codes and modifiers.
A physician, ARNP or PA. The form asks for the physician's printed name, Kansas Medicaid provider ID and Kansas NPI, then the signature and date. The prescriber also states whether the patient has been seen and diabetes control evaluated within the last 6 months.
KMAP returns it unprocessed if it is not completed in its entirety, and the prior authorization is denied if the request is not received within 15 working days. Every field matters, including testing frequency, length of need, insulin injections per day and the reason for more frequent testing.