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DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Medicaid Services F01153 (10/2022)FORWARDHEALTH BREAST PUMP ORDERForwardHealth requires certain information to enable the programs to authorize
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What is Revised Coverage Criteria for Breast Pumps Form?

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Revised coverage criteria are guidelines established to update and clarify the eligibility requirements for coverage under specific programs or policies.
Entities such as healthcare providers, insurance companies, or program administrators are required to file revised coverage criteria to ensure compliance with updated regulations.
To fill out revised coverage criteria, individuals or organizations must follow the specified format, provide necessary documentation, and submit it to the relevant governing body or authority.
The purpose of revised coverage criteria is to ensure that coverage policies reflect current standards, address new technologies or treatments, and meet the needs of beneficiaries.
Information reported on revised coverage criteria should include updates on eligibility, benefits, coverage limitations, and any relevant supporting data or research.
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