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|Certificate of Medical Necessity: |[pic] |
|Speech Therapy | |
| |
|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:
| |
| |
| |
| |
|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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