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|Certificate of Medical Necessity: |[pic] |

|Speech Therapy | |

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|Fax or mail this | |For Pre-Service: Statewide Fax (877) 219-9448 |

|completed form | |For Medicare Advantage (BlueMedicare) HMO and PPO Plans: Fax (904) 301-1614 |

| | |For Post-Service Claims: |

| | |Florida Blue |

| | |P.O. Box 1798 |

| | |Jacksonville, FL 32231-0014 |

|Section A |

|Physician Information/ |Name:       |BCBSF No:       |National Provider Identifier (NPI):       |

|Requesting Provider | | | |

| |Contact Name:       |Phone:       |

|Facility Information/ |Name:       |BCBSF No:       |National Provider Identifier (NPI):       |

|Location where services will be| | | |

|rendered | | | |

| |Contact Name:       |Phone:       |

|Member Information |Last Name:       |First Name:       |

| |Member/Contract Number (alpha and numeric):       |Date of Birth:       |

|Procedure Information |Procedure Code(s):       |Procedure Description:       |

| |Diagnosis code(s):       |Diagnosis Description:       |

| |Date of Service/Tentative Date:       |

|Section B |

|Medical Necessity: For detail information on speech therapy, including the criteria that meet the definition of medical necessity, recertification of the plan|

|of care, and contract benefits, visit the Florida Blue Medical Coverage Guideline website at . Refer to Medical Coverage Guidelines |

|01-92506-01, Speech Therapy Services. |

Check any boxes and complete all entries that apply:

|Section C |

|This is: an initial evaluation a re-evaluation continuation of therapy |

| Yes | No |Is this request related to a maintenance therapy plan? |

| Yes | No |Is this a request for an anti-stuttering device? |

| Yes | No |Is the member receiving concomitant occupational therapy? |

| Yes | No |If Yes, is there a separate treatment plan and goals for the occupational therapy? |

|Was a comprehensive speech therapy evaluation performed documenting the following criteria? |

|Check all that apply: |

| |Specific statements regarding history and diagnosis |

| |Standardized age-appropriate testing results |

| |Specific short-term and long-term goals with measurable objectives |

| |The specific treatment techniques and/or exercises to be used in the treatment |

| |The frequency and duration of the treatment. |

| |Frequency of treatment:       Duration of treatment:       |

|Is the request for speech therapy intended to restore or improve speech in members who have a swallowing or speech-language disorder? |

|Check all that apply: |

| |An illness or condition (e.g. dysphagia, GERD) |

| |Specify:       |

| |An exacerbation of a chronic illness or condition |

| |Specify:       |

| |An injury or trauma |

| |Specify:       |

| |A surgical procedure |

| |Specify:       |

| |A congenital defect (e.g., cleft palate, cleft lip, etc.) |

| |Specify:       |

| |Cerebrovascular accident (stroke) |

|Is the request for speech therapy for one or more of the following conditions? |

|Check all the apply: |

| |Behavioral disorders |

| |Learning disabilities |

| |Stammering or stuttering |

|Section D – Coverage for Autism Spectrum Disorders |

|Does the request for speech therapy meet the following criteria? |

|Check all that apply: |

| |Therapy services are rendered in accordance with the treatment plan as prescribed by the treating physician and updated no less than every six (6) months|

| |The therapy treatment plan contains the diagnosis, the proposed treatment type, frequency, and duration of the treatment with the outcomes stated as |

| |goals |

| |Includes the frequency of update to the treatment plan and the treating physician signature |

| |The therapy rendered is considered the standard of care for the condition diagnosed by the treating physician. |

|Section E – Medicare Members Only |

| Yes | No |Is there documented improvement of the member’s condition? |

Additional Comments:

|      |

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|I hereby certify that (i) I am the treating physician for above member, (ii) the information contained in and included with this Certificate of Medical |

|Necessity is true, accurate and complete to the best of my knowledge and belief, (iii) the member’s medical records contain all appropriate documentation |

|necessary to substantiate this information. I acknowledge that a determination made based upon this Certificate of Medical Necessity is not necessarily a |

|guarantee of payment and that payment remains subject to application of the provisions of the member’s health benefit plan, including eligibility and plan |

|benefits. Additionally, I further acknowledge and agree that Florida Blue may audit or review the underlying medical records at any time and that failure to |

|comply with such request may be a basis for the denial of a claim associated with such services. |

|Ordering Physician’s Signature: |Date:       |

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