942i Instructions for IME Verification Form | Medicaid

“Name of Medicaid Member” (Must be A/R) and “Medicaid ID# (either SUCCESS or MHN ID #)

“Name of Customer” (must be A/R), “Date of Service”, “Cost of service” (cost of Rx , procedure, orthodic, etc.)

“Description of Services Give NDC# for Drugs” (describe what was provided, if RX provide NDC #)

For “Drugs” provide the # of tablets or capsules and the # of grams or milliliters.

The question, "Was this service ordered in writing by a doctor?" must be answered YES. If NO, it can’t be considered as an IME.

“Is the customer financially obligated to pay for the Above Services?” In order to be considered as an IME, the answer must be YES.

“Are you a Medicaid–participating provider? Must be answered Yes or No.

The pharmacist must answer questions 1 – 4 if the service was for a drug.

“Name of Medical Care Provider” must be typed or printed.

The provider must include his/her Provider Number in the space “Medicaid Provider Number”.

“Signature of Provider” - The signature of the provider must be an original signature; photocopied or stamped signatures are unacceptable.

The “Date” should be the date signed by the provider.