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Provider and Facility Reference Manual

Section 6 - How to Obtain Utilization Management (UM) Preauthorization

Please refer to the Stat Bulletins, Clinical Protocols, and Code & Comment (found on our website) and contacting Provider Service with questions for additional information and detail as to whether a procedure requires preauthorization.
To obtain preauthorization for medical/surgical procedures:

Please fax your request* along with supporting clinical documentation such as, but not limited to: history and physical, office notes, radiology studies, medical testing, and conservative treatments/therapy notes to our Utilization Management Department at (716) 887-7913. Please include the following information:

  • Member's name, date of birth and ID number
  • Diagnosis code(s)
  • Current Procedural Terminology (CPT) code and /or Healthcare Common Procedure Coding System (HCPCS) code
  • Date of service
  • Facility name
  • Requesting MD name and address
  • Tax ID number
  • Office phone number
  • Office fax number
  • Office contact

*UM forms are available on our Provider website.

Durable Medical Equipment/Prosthetics/Orthotics

Blue Cross Blue Shield will pay for basic, standard durable medical equipment (DME) which has been determined to be medically necessary. Coverage is dependent upon member contract exclusions and benefit limitations. We will determine whether the item should be purchased or rented.

Durable medical equipment is equipment which is intended for repeated use, and is primarily and customarily used to serve a medical purpose. These items are generally not useful to a person in the absence of disease, illness or injury, and are appropriate for use in the patient's home.

We follow the Centers for Medicare & Medicaid Services (CMS) billing guidelines for upgraded DME items. The member has no financial liability for the cost of an upgraded item or components unless he or she makes an informed decision by signing a financial liability form (for Medicare Advantage members, this form is the Advance Beneficiary Notice of Non-coverage (ABN)). An upgrade refers to a piece of equipment that is medically unnecessary because it exceeds the member's medical needs or has a medically unnecessary component that is in excess of medical needs (e.g., deluxe model or deluxe features). This process cannot be used as a way to cover increased costs (e.g., batteries for a wheelchair that have been provided with no additional charge to the member cannot be labeled as an upgrade in order to receive additional money because the cost of the wheelchair has increased).

  • Specific durable medical equipment, as defined by the Utilization Management Department, is subject to the preauthorization process unless determined to be exempt from this process. Please refer to Code & Comment.

  • Utilization Management reviews requests for durable medical equipment to determine if all of the requirements as listed are satisfied:
    • Equipment is prescribed by a practitioner within the scope of his/her license.
    • DME equipment must be medically necessary and meet criteria.
    • No coverage is available for equipment that Blue Cross Blue Shield has determined is not reasonable. When a claim is filed for equipment containing features of an athletic nature, features of a medical nature that are not required by the patient's condition or deluxe features when standard equipment meets the member's needs, the amount payable is based on the allowance for the equipment without the added features.

Preauthorization Exempt Codes

  • Blue Cross Blue Shield requires that preauthorization be obtained for coverage of certain DME and certain prosthetics/orthotics. Updates to this listing will be communicated via Stat Bulletins. Please refer to Code & Comment.

DME Rental Policy

When a DME provider’s assets are purchased by another provider, the policy for the rental of a capped DME item for our members receiving these services is as follows:

  • If the change occurs during an active phase of equipment rental, the previous rental months are counted. We will continue monthly rental payments to the new DME provider until the capped rental is met, at that point, the item is considered owned by the member.
  • The new purchasing provider may not start a new rental cycle period at the time of acquisition of the previous provider’s assets.  It is the same piece of equipment for the same patient. Equipment rental is based on the member’s benefits regardless of who is providing the service.

Repairs and Replacement Parts

We utilize CMS guidelines when considering repair and/or part replacement of DME for reimbursement. Key provisions include:

  1. The item must be owned by the member and no longer covered under warranty
  2. No reimbursement will be made if the repair expense exceeds the expense of purchasing a replacement
  3. A valid HCPCS code specifically describing the replacement part must be used, if available. If there is not a valid HCPCS code, use the modifier RB with the code that best describes the piece of equipment
  4. Invoices for replacement parts must be included with your claim

All DME, prosthetic and orthotic items billed to us require a prescription. The prescription must be signed and dated by a qualified provider.