ELEMENTS REQUIRED

1. RX Date
2. Patient's Name
3. CPAP/BiPAP Equipment Being Ordered
1. CPAP
2. BiPAP
3. BiPAP with Backup
4. CPAP/BiPAP Equipment Settings
5. Supplies, not all supplies need to be listed OR All Necessary Supplies OR RX form OR Parachute generated order are acceptable
6. Licensed Practitioner Name
7. Signature of Licensed Practitioner

Date Policy

Must be within 12 months

ELEMENTS REQUIRED

1. RX Date
2. Patient's Name
3. CPAP/BiPAP Equipment Being Ordered
1. CPAP
2. BiPAP
3. BiPAP with Backup
4. CPAP/BiPAP Equipment Settings
5. "All Necessary Supplies" is not acceptable. Supplies need to be listed OR RX form OR Parachute generated order are acceptable
6. Licensed Practitioner Name
7. Signature of Licensed Practitioner

Date Policy

Must be within 12 months

SOW (Standard Written Order)
MUST be in supplier's possession BEFORE the PAP MACHINE is delivered/shipped/dispensed

ELEMENTS REQUIRED

1. Date of SOW/Rx (STAMPS NOT ALLOWED)
2. Patient's Name
3. CPAP/BiPAP Equipment Being Ordered
*Must align with HCPC being billed*
1. CPAP
2. BiPAP
3. BiPAP with Backup
4. CPAP/BiPAP Equipment Settings
5. "All Necessary Supplies" is not accepted. Supplies need to be listed. Blanket RX, RX Form or Parachute orders are acceptable
6. Ordering Licensed Practitioner Name or NPI#
7. Signature of Ordering Licensed Practitioner (STAMPS NOT ALLOWED)
*If there is a date field next to the signature, a date needs to be entered, cannot leave blank*

Date Policy

Must be completed within 90 days of setup date

ELEMENTS REQUIRED

1. Patient's Name
2. Patient's Date of Birth
3. Equipment Being Ordered
1. CPAP
2. BiPAP
3. BiPAP with Backup
4. CPAP/BiPAP Equipment Settings
5. Description of Supplies Being Ordered
1. Supplies need to be individually listed (Blanket RX acceptable)
6. Ordering Licensed Practitioner Name
7. Ordering Licensed Practitioner NPI #
8. Signature of Ordering Licensed Practitioner
9. Signature Date of Ordering Licensed Practitioner

Date Policy

Must be within 12 months

Verify Doctor

Ordering doctor MUST be a RI Medicaid provider

Verify here: https://providersearch.riproviderportal.org/ProviderSearchEOHHS/ProviderSearch.aspx

ELEMENTS REQUIRED

1. Date of Rx
2. Patient's Name
3. Patient's Date of Birth
4. Equipment Being Ordered
1. CPAP
2. BiPAP
3. BiPAP with Backup
5. CPAP/BiPAP Equipment Settings
6. Description of Supplies Being Ordered
1. Supplies need to be individually listed (Blanket RX acceptable)
7. Ordering Licensed Practitioner Name and Address
8. Ordering Licensed Practitioner NPI #
9. Signature of Ordering Licensed Practitioner
*If there is a date field next to the signature, a date needs to be entered, cannot leave blank*

Date Policy

Must be within 12 months

Verify Doctor

Ordering doctor MUST be a NH Medicaid provider

Verify here: https://nhmmis.nh.gov/portals/wps/portal/FindaHealthCareProvider

ELEMENTS REQUIRED

1. Date of Rx
2. Patient's Name
3. Patient's Address
4. Patient's Date of Birth
5. Equipment Being Ordered
1. CPAP
2. BiPAP
3. BiPAP with Backup
6. CPAP/BiPAP Equipment Settings
7. Diagnosis Associated with Prescribed Therapy
8. Description of Supplies Being Ordered
1. Supplies need to be individually listed (Blanket RX acceptable)
9. Length of Need (e.g. 99 or Lifetime)

10. Ordering Licensed Practitioner Name and Address
11. Signature of Ordering Licensed Practitioner
12. Signature Date of Ordering Licensed Practitioner

Date Policy

Must be within 12 months

Verify Doctor

Ordering doctor MUST be a Husky approved provider for CT

ELEMENTS REQUIRED

1. Date of Rx
2. Patient's Name
3. CPAP/BiPAP Equipment Being Ordered
1. CPAP
2. BiPAP
3. BiPAP with Backup
4. CPAP/BiPAP Equipment Settings
5. Description of Supplies Being Ordered
1. Supplies need to be individually listed (Blanket RX acceptable)
6. Licensed Practitioner Name
7. Signature of Licensed Practitioner
*If there is a date field next to the signature, a date needs to be entered, cannot leave blank*

Date Policy

Must be within 12 months

ACCEPTABLE FORMS

1. Ordering Practitioner Order Form (e.g. Rx Pad or Order Sheet)
2. Practitioner Letterhead
3. Medicare Certificate of Medical Necessity

ELEMENTS REQUIRED

1. Dated NO MORE than 90 Days Prior to Initial Date of Service
2. Patient's Name
3. Patient's Address
4. Patient's Medicaid ID Number (RID) or the # on the Patient's Medicaid Card
5. Equipment Being Ordered
1. CPAP
2. BiPAP
3. BiPAP with Backup
6. CPAP/BiPAP Equipment Settings
7. Supplies can be listed but not required
8. Diagnosis Associated with Prescribed Therapy
9. Specific Therapeutic Objectives
1. (example) To treat OSA
10. Frequency of Use:
1. (example) To use nightly
2. (8 & 9 can be combined:Example: For Nightly Use to Treat OSA)
11. Length of Need (e.g. 99 or Lifetime) or a Start Date & End Date is acceptable

12. Licensed Practitioner Name, Address, Phone Number
13. Signature of Licensed Practitioner OR Independent Nurse Practitioner (STAMPS NOT ALLOWED)
14. Signature Date of Ordering Licensed Practitioner (STAMPS and/or TYPED NOT ALLOWED)

Date Policy

Must be within 90 Days of setup date (DOS)

Verify Doctor

Ordering doctor MUST be a MA Medicaid provider

Verify here: https://masshealth.ehs.state.ma.us/providerdirectory/

ELEMENTS REQUIRED

1. Date of Rx
2. Patient's Name
3. CPAP/BiPAP Equipment Being Ordered
1. CPAP
2. BiPAP
3. BiPAP with Backup
4. CPAP/BiPAP Equipment Settings
5. Supplies, not all supplies need to be listed OR All Necessary Supplies
6. Licensed Practitioner Name
7. Signature of Licensed Practitioner
8. Signature Date of Ordering Licenses Practitioner

Date Policy

Must be within 12 months

Work In Progress WIP State	Owner
*7.1 Autoconfirm Pushback	Nikki Krakauer
.1 - CS Pending Order	Branch Manager
.3 - OC Pre confirmation	No Action
.3.1.1 Snap Ops Pushback	Jaime Martin
.3.1-OC Pushback to CS	Move to .3.1.1
.3.3 - OC Tracking Info Incomplete	Bianca Lehman
.3.3.1 - OC Pending Delivery Confirmation	Nikki Krakauer
.3.4 - Need Prior Authorization	Katie Norris
.4 - BILLING Ready to bill	Nikki Krakauer
NEED PRIOR AUTH	Katie Norris
PTAN Not Licensed in State - Correction Needed	Branch Manager