Standardized Authorization Forms for Home Health and Hearing Aid Services
Date: 10/24/18
Heritage Health (Medicaid):
Nebraska Total Care is issuing the following guidance for Home Health and Hearing Aid providers related to updates to the prior authorization request process:
The Nebraska Medicaid and Long-Term Care Administrative Simplification committee has now approved a standardized Home Health authorization form to be used by all MCO’s, effective immediately. Please access and utilize the Home Health Authorization Request Form MS-72 (search MS-72) on a go forward basis.
- Please ensure you continue to submit all supporting clinical documentation to substantiate the medical necessity of services along with the standardized Home Health authorization request form
- The Home Health authorization form can be completed and attached for submission via the provider portal when appropriate
The Nebraska Medicaid and Long-Term Care Administrative Simplification committee has now approved a revised and standardized MS-76 form to be utilized for Hearing Aid authorization requests, effective immediately. A fillable version of the Hearing Aid Authorization Request Form MS-76 (search MS-76) should be utilized on a go forward basis.
- Please ensure you continue to submit all supporting clinical documentation to substantiate the medical necessity of services along with the standardized Hearing Aid MS-76 authorization request form
- The Hearing Aid authorization form can be completed and attached for submission via the provider portal when appropriate
If you have questions, please contact Provider Relations.
Update 7/15/19: Physician's Report on Hearing Loss DM-5H (search DM-5H)