Basics of Preauthorization for DME

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Basics of Preauthorization
for DME
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Basics of Preauthorization for DME
Preauthorization is a process through which a
request for provisional affirmation of coverage
is submitted for review before a durable medical
equipment, prosthetics, orthotics, and supplies
(DMEPOS) item is furnished to a beneficiary and
before a claim is submitted for payment.
Preauthorization helps ensure that applicable
coverage, payment, and coding rules are met
before supplies are delivered. Preauthorization
may be needed before certain services can be
rendered or equipment supplied. Every insurance
company has its unique guidelines for
preauthorization for DME, still, in this article,
we shared the basics of preauthorization for
general understanding purposes. DME coverage is
subject to the members benefit plan. Members may
be responsible for paying a portion of the DMEs
cost in the form of a co-pay/coinsurance and/or
deductible. Generally, the DME provider will
notify the member when co-pays/coinsurance and/or
deductibles are due. You can submit a
pre-authorization request in multiple ways. Most
insurance companies accept preauthorization
requests for DME through online (provider
portal) by fax and by phone. You will receive
notification about pre-authorization requests by
fax, via standard U.S. mail and online (provider
portal). In the event there is an urgent request
for equipment requiring preauthorization that
needs to be ordered on a weekend or on a holiday,
most of the payers provide an emergency prior
approval phone line. Key Elements of
Preauthorization for DME 1. DME Preauthorization
Request Checklist DME preauthorization request
checklist list includes the preauthorization
request form certificate of medical necessity
written prescription and patients medical
records with details
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Basics of Preauthorization for DME

• (such as diagnosis, patient history, physical
  exam findings, progress notes, medication list,
  wound or incision/location).
• 2. Certificate of Medical Necessity
• The requesting physician, not the DME supplier,
  is responsible for completing the certificate of
  medical necessity for all prescribed DME items.
  The certificate of medical necessity may,
  however, be submitted by the requesting
  physician, discharging facility, or DME supplier.
  A preauthorization request submitted without a
  certificate of medical necessity will be denied
  for lack of information. Waiting to submit the
  preauthorization request until this is ready will
  save time and reduce rework. Filling out the
  certificate of medical necessity form involves
• Certifying the patients need. The treating
  physician must certify in writing the patients
  medical need for equipment and attest the patient
  meets the criteria for medical devices and/or
  equipment.
• Issuing a plan of care. The treating physician
  must issue a plan of care for the patient that
  specifies the type of medical devices, equipment
  and/or services to be provided and the nature
  and frequency of these services.
• 3. Written Prescription
• To initiate coverage of DME, the requesting
  physician must issue a prescription, or other
  written order on personalized stationery, which
  includes
• Members name and full address
• Providers signature (Signature stamps are not
  acceptable.)

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Basics of Preauthorization for DME

• Date the provider signed the prescription or
  order
• Description of the items needed
• Start date of the order (if appropriate)
• Diagnosis
• A realistic estimate of the total length of time
  the equipment will be needed (in months or years)
• Electronic requests for DME preauthorization
  should be accompanied by a fax containing the
  written prescription and any applicable
  certificate of medical necessity forms.
• 4. Reconsideration and Appeals Process
• Cases that do not meet medical necessity may be
  reconsidered (have a peer-to-peer discussion) or
  appealed.
• Reconsideration process A reconsideration is a
  post-denial, pre-appeal opportunity to provide
  additional clinical information. Reconsideration
  must be requested within 2 to 3 weeks of the
  initial denial date. Peer-to-peer (P2P) review
  requests can also be made verbally or in writing.
  P2P results in either a reversal or an upholding
  of the original decision. The requestor and the
  member are notified via mail and fax.
• Appeals process Insurance companies generally
  mention the appeals process in the denial letter.
  The provider can submit appeals in the same ways
  (online, phone, fax) as they submitted a
  preauthorization request.
• DME suppliers who submit bills to insurance
  companies must keep the providers original
  written order or prescription in their files.
  Providers are advised to document the medical
  need for and utilization of DME items in the
  members chart and to ensure information about
  the members medical condition is correct.

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Basics of Preauthorization for DME
In the event of a medical audit, payers may
require copies of relevant portions of the
patients chart to establish the existence of
medical need as indicated in the certificate of
medical necessity form submitted with the
preauthorization request. Preauthorization for
Medicare CMS recently announced the final rule
for certain DMEPOS items. This final rule
establishes a preauthorization process for
certain DMEPOS items through two steps. First,
the rule establishes a Master List of DMEPOS
items that are frequently subject to unnecessary
utilization and potentially subject to
preauthorization based on certain criteria.
Second, it creates a Required Prior
Authorization List, a subset of items on Master
List that are subject to preauthorization. CMS
announced that it would inform the public of
those items on the Required Prior Authorization
List by publishing a notice in the Federal
Register with 60 days notice before
implementation. It could be difficult for DME
suppliers and providers to keep track of DME
items requiring preauthorization. Legion
Healthcare Solutions can assist you in
preauthorization for DME items. We are a leading
medical billing company providing complete
billing and coding services. Our experienced
billers are fully aware of the DME items list
requiring preauthorization. We are well-versed in
the preauthorization process for DME for various
insurance companies. To know more about our
preauthorization services for DME, contact us at
727-475-1834 or email us at info_at_legionhealthcares
olutions.com
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