(HMK) - DME Form - Blue Cross and Blue Shield of Montana

Prior Authorization Request – DME,Prosthetics, or Orthopedic DevicesIf the purchase price over $500, complete this form. If the purchase price is not over $500, call Customer Service at1-800-447-7828 to determine if prior authorization is necessary. If prior authorization is necessary, complete this form.Specific coverage criteria for some items are explained in medical policy published at www.bcbsmt.com or in themember’s contract.CPAP-type devices do not need prior authorization. However, rental for three months prior to initial purchase isnecessary.Patient Name: Patient Health Plan ID: Patient Date of Birth:Provider Name: Provider NPI Number: Provider Phone:Provider Fax:Ordering Provider Name:Ordering Provider Telephone:HCPCS or CPTCodeDiagnosis CodeRental (RR) orPurchase (NU)Price Replace Upgrade RepairUnlisted Code Description:Replace/Upgrade Reason:Type of Repair:Fax: (406) 441-4624, Attention: Prior Authorization orMail: Medical Review Department, Blue Cross and Blue Shield of Montana, P.O. Box 4309, Helena, MT59604 Note: Do not mail form if already faxedTo Be Completed By BCBSMT Approved - Authorization Number: DeniedComments:Reviewed by:Date:Prior authorization approves the medical necessity and appropriateness of the services requested. The determination for payment ofclaims is made when the claim is received. The claim is subject to the terms and limitations of the member’s benefit plan, includingapplicable co-payments. Prior authorization is only honored if the member is enrolled in HMK at the time services are rendered. HMKparticipating providers accept the HMK allowable as payment in full as specified in the provider agreement. HMK participatingproviders agree to bill the HMK member only for applicable copayments and for non-covered services the HMK member has agreed topay in writing in advance of receiving services.03/06/2013: C:\Documents and Settings\exaglk\Desktop\Prior Auth Form HMK-DME.doc1 of 2

Additional line itemsHCPCS or CPTCodeDiagnosis CodeRental (RR) orPurchase (NU)Price Replace Upgrade RepairUnlisted Code Description:Replace/Upgrade Reason:Type of Repair:Provider Participation NoticeHealthy Montana Kids (HMK) members are required to use HMK participating providers when seeking medical treatmentand all providers involved with this procedure must be HMK participating providers. Call Blue Cross and Blue Shield ofMontana at 1-800-447-7828, Extension 6100, to enroll in the network prior to rendering services or to inquire aboutwhether the provider to whom you are referring an HMK member is an enrolled HMK participating provider.03/06/2013: C:\Documents and Settings\exaglk\Desktop\Prior Auth Form HMK-DME.doc2 of 2