Effective immediately, providers must submit the “Evaluation Form for Prosthetics, Prosthetic Components, and Replacement Requests” along with the Telligen prior authorization request. This requirement applies only to prosthetics, prosthetic components, and prosthetic replacements assigned an L HCPCS code. The Evaluation Form should be completed collaboratively by the treating prescriber and the prosthetist, with each party filling out their designated sections. A copy of the form can be found under “Forms” in the Document Library at telligenmd.qualitrac.com.