PRC-Saltillo response to COVID-19: prc-saltillo.com/covid-19
The journey to AAC begins with having the right paperwork you need to obtain your device.
Before you begin your submission, make sure you have the proper documentation. Regardless of the method of purchase, your funding source will require paperwork – be sure you have what you need to begin the process.
These are the documents that every submission, regardless of funding source or state of origin, requires. You’ll need to download and complete these in full.
Please note that some states require the use of a state specific form for Medicaid submissions and should be used in lieu of the Certificate of Medical Necessity (found at the link below). State specific forms are located in the State Documents tab.
In addition to the required documentation from the previous tab, please be sure to include paperwork that indicates what device you are purchasing, accessories needed, etc.
| PRC Equipment Selection Sheet - Accent Products & Accessories|| NovaChat Selection Sheet|
| PRC Equipment Selection Sheet - PRiO Products & Accessories|| TouchChat Express Selection Sheet|
| PRC-Saltillo Via Pro Selection Sheet|
| Mounting Selection Sheet|
| PRC & Saltillo Switch Selection Sheet|
Only needed if a trial is being requested.
If you are not submitting the device purchase as an insurance or Medicare/Medicaid claim, you can pay to trial a device using the forms below.
Funding through Medicare will also require documentation. If you’re using this option to obtain a device, please download these documents to complete your submission.
Local Coverage Determination
LCD for Speech Generating Devices (L11524) documentation requirements: The patient’s medical records will reflect the need for the care provided. You may be asked to provide this documentation if requested by the paying source (Medicare). More information can be found on the CMS website by searching on L11524 Local Coverage Determination for Speech Generating Devices.
Physician's Progress Notes
The Centers for Medicare & Medicaid Services (CMS) require that the physician provide progress notes from the face-to-face examination for the speech generating device (SGD) and accessories. The physician must document that the beneficiary was evaluated and/or treated for a condition that supports the medical necessity of the SGD and accessories. These progress notes must accompany the CMN. The progress notes needs to be signed by a PECOS certified physician.
Medicare Advance Beneficiary Notice (if applicable)
AAC Funding will send this form to the beneficiary if its needed. The Advanced Beneficiary Notice is used if it is determined that Medicare will not pay for an item.
Should your device require service, if repair is planned to be paid for by private insurance, Medicaid or Medicare, then check here first to obtain any documents you’ll need to facilitate the repair.
Prescription from Physician
List specific device to be repaired.
Statement of Abuse or Neglect
Statement written by the SLP stating that the device repair is not from Abuse or Neglect by the client.
Repair Evaluation Form
This form may be used instead of the Letter of Recommendation from a Speech Language Pathologist (SLP).