Prior Authorization Request (PAR) Coversheet
JURISDICTION B
Power Mobility Demonstration
Request DateNumber of Pages (including coversheet)
For HCPCSInitial Request OR Subsequent Request
Entity Submitting Supplier Physician/Treating Practitioner (TP)
Supplier NamePhysician/TP Name
Supplier AddressPhysician/TP Address
Supplier PhonePhysician/TP Phone
Supplier Contact NamePhysician/TP Fax
Supplier FaxPhysician/TP NPI
Supplier NPI
Supplier PTAN
Beneficiary NameBeneficiary HICN
Beneficiary State of ResidenceBeneficiary Date of Birth
Expedited Request?YesNo
Note: Expedited requests require justification to meet expedited requirements.
Expedited Request Justification
Checklist of PAR information to include: Fax the PAR to: 1.615.660.5992
•Completed coversheetOR
•7-element orderMail the PAR to: CGS
•Face-to-Face assessmentDME Medical Review - Prior Authorization
• Detailed product description PO Box 23110
• Specialty evaluation (if required by policy) Nashville, TN 37202-4890
• Other relevant medical documentation
For additional information, such as the medical policy, please visit our website
at: http://www.cgsmedicare.com/jb/mr/power_mobility_resources.html
Originated July 5, 2016.
© 2016 Copyright, CGS Administrators, LLC.