Tura's Pharmacy Inc.
85 Summer St
Kingston MA,02364
(tel) 781-585-2595 (fax) 781-585-8266
"Personalized Hometown Service"
www.turaspharmacy.com
Dr._________________________
Phone_______________________Fax___________________
RE: Request for medical documentation concerning Diabetes Testing Supplies for:
Patient________________________Date of Birth_________________
Patient is currently testing ouside of Medicare Guidelines according to Medicare Policy
Additional documentation requirements apply to: 1) a diabetic patient who is not insulin treated (KS modifier present) and whose prescribed frequency of testing is more often that once per day, or 2) a diabetic patient who is insulin-treated (KX modifier present) and whose prescribed frequency is more often than three times per day.
In order for the patient to receive larger than normal quantities of testing supplies, we must have on file at the pharmacy a current "Chart Notes" explaining why testing is outside the above guidelines
Medicare will only cover strips and lancets in an amount in excess of those listed above in the following circumstances:
- The treating physician has ordered a frequency of testing that exceeds the utilization guidelines and has documented in the patient's medical record the specific reason for the additional strips for that particular patient; and
- The treating physician has seen the patient and has evaluated their diabetes control within six months prior to ordering quantities of strips or lancets that exceed the utilization guidelines; and
-
If refills of quantities of supplies that exceed the utilization guidelines are diepensed, there must be documentation in the physician's records (i.e. A specific narrative statement that adequetly documents the frequency at which the patient is actually testing or a copy of the beneficiary's log) or in the supplier's record (i.e. A copy of the beneficiay's log) that the patient is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the patient is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months
Chart Notes must be faxed to the pharmacy before the Patient can get
Additional Testing Supplies.
Please call the pharmacy, or contact us through our website with any questions. We appologize for this inconvenience. Our goal is to get the patient the correct and necessary amount of testing supplies needed for proper care.
Pharmacist requesting this information:_________________________