17.3.17.1 Wheelchair Authorization RequirementsWritten requests for prior authorization and authorization of all wheelchairs must include the following two forms: Note: The physician's signature is only required on page 1 of the form in the Statement of Medical Necessity section. Providers must submit page 1 of the form to TMHP. Pages 2 through 5 are only required for certain DME requests. Refer to the text under the form title to determine which of these pages must be submitted in addition to page 1.
• A PT or an OT who is not employed by the DME provider must complete the evaluation and the CSHCN Services Program Wheelchair Seating Evaluation Form. Authorization for wheelchair modifications or repairs for an existing seating system also require the wheelchair seating evaluation. CSHCN Services Program-approved custom DME providers are required to submit these assessments with their requests for the wheelchairs. Therapists must use the "CSHCN Services Program Wheelchair Seating Evaluation Form," on page B-117. |
