(HMK) - DME Form - Blue Cross and Blue Shield of Montana
(HMK) - DME Form - Blue Cross and Blue Shield of Montana
(HMK) - DME Form - Blue Cross and Blue Shield of Montana
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Additional line itemsHCPCS or CPTCodeDiagnosis CodeRental (RR) orPurchase (NU)Price Replace Upgrade RepairUnlisted Code Description:Replace/Upgrade Reason:Type <strong>of</strong> Repair:Provider Participation NoticeHealthy <strong>Montana</strong> Kids (<strong>HMK</strong>) members are required to use <strong>HMK</strong> participating providers when seeking medical treatment<strong>and</strong> all providers involved with this procedure must be <strong>HMK</strong> participating providers. Call <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong> <strong>Shield</strong> <strong>of</strong><strong>Montana</strong> 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 <strong>HMK</strong> member is an enrolled <strong>HMK</strong> participating provider.03/06/2013: C:\Documents <strong>and</strong> Settings\exaglk\Desktop\Prior Auth <strong>Form</strong> <strong>HMK</strong>-<strong>DME</strong>.doc2 <strong>of</strong> 2
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