Insurance Pre-Authorization Form Template

Section 4: Equipment Specifications

Prescribed Durable Medical Equipment:

Underarm Crutches (Axillary Crutches)

HCPCS Code: E0114 (pair) | Typical Coverage: Standard

Forearm Crutches (Lofstrand Crutches)

HCPCS Code: E0116 (pair) | Typical Coverage: May require justification

Platform Crutches

HCPCS Code: E0118 (pair) | Requires Medical Justification (e.g., wrist/hand injury)

If prescribing forearm or platform crutches, explain medical necessity vs. standard underarm crutches:

Quantity and Specifications:

Item	Quantity	Specifications
Crutches (pair)
Replacement Tips
Hand Grips (optional)

Section 5: Physician Certification and Signature

I certify that the information provided above is accurate and complete. The prescribed durable medical equipment is medically necessary for this patient's diagnosis and treatment plan. The patient has been evaluated and trained in proper use of this equipment.

Physician Signature:

Print Name:

Date Signed:

Physician Credentials:

(e.g., MD, DO, DPM)

📤 Submission Instructions

Step-by-Step Submission Process:

Before Submission - Verify Information:
- All fields completed accurately
- Physician signature and date present
- ICD-10 codes are current and correct
- HCPCS codes match equipment prescribed
Determine Submission Method: Call insurance customer service to confirm:
- Fax number for DME pre-authorization department
- Mailing address (if required)
- Online portal availability
- Required reference or case number
Submit Form: Send via preferred method with fax confirmation or tracking
Follow Up: Call insurance in 3-5 business days to verify receipt and status
Authorization Decision: Typically received in 5-10 business days

Common Submission Methods:

Method	Pros	Instructions
Fax	Fastest, instant confirmation	Get fax confirmation page. Keep for records. Call to verify receipt next day.
Online Portal	Trackable, electronic record	Scan completed form. Upload to insurer's member portal. Save confirmation number.
Mail (Certified)	Official paper trail	Send via certified mail with return receipt. Keep tracking number.
Physician Office	Office handles submission	Some practices submit directly. Confirm they've sent and get reference number.

Important Contact Information (Fill in Your Details):

Insurance Customer Service Phone:

DME Pre-Authorization Fax Number:

Reference/Case Number (if assigned):

Date Submitted:

Expected Decision Date:

⚠️ If Pre-Authorization is Denied:

Request written denial letter with specific reason
Ask about appeals process and timeline
Have physician provide additional medical documentation
Consider peer-to-peer review (doctor speaks directly to insurance medical reviewer)
File formal appeal within stated timeframe (usually 60-180 days)
Contact your state's insurance commissioner if appeals exhausted

💡 Tips for Faster Approval:

Submit as soon as physician completes (don't delay)
Include ALL required fields - incomplete forms cause delays
Use specific medical terminology in justification
Reference clinical studies or treatment guidelines if applicable
Request "expedited review" if urgent medical need (document reason)
Keep copies of everything submitted and all correspondence

CrutchesGuide.com | Your Resource for Mobility Equipment Coverage

📧 [email protected] | 🌐 www.crutchesguide.com

Disclaimer: This template is for informational purposes only and does not constitute legal or medical advice. Insurance requirements vary by provider and plan. Always verify specific requirements with your insurance company. CrutchesGuide.com is not affiliated with any insurance provider.

📋 Insurance Pre-Authorization Form

Section 1: Patient Information

Section 2: Prescribing Physician Information

Section 3: Medical Necessity (To Be Completed by Physician)

Weight-Bearing Status:

Medical Justification:

Functional Limitations (check all that apply):