Helpful Hints for Durable Medical Equipment Authorization Requests

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Obtaining an Initial Authorization:

Fax: All requests for durable medical equipment (DME) are processed by fax only. Passport Health Plan DME request forms are available by clicking here.

Who to contact if you have questions: If you need to speak to someone in DME, please call the DME precertification line to leave a confidential message. The DME voicemail message will identify the current date of faxes being processed for that day.

After Hours/Weekends Policy: 

• When leaving a message, please leave a return phone number, along with the member’s name and ID number. If you are checking on the status of your request, please also leave the date you sent the original fax.
• You must notify Passport Health Plan’s DME precertification line prior to supplying or within 24 hours (one business day) after the member has received the item. If on a holiday or weekend, Passport Health Plan must be notified next business day.
• If a request for DME services is not received within the required time frame an administrative denial will be issued.

Completing the Authorization Process

• Please keep your fax confirmation copy until the request has been processed.
• The DME request form is to be completed with all information required. You must state if the request is for a rental (RR) or a purchase (NU). If your request is for a rental item, please mark the duration of rental in the quantity section. Practitioner orders must state duration of need.
• All DME requests must be accompanied by a signed and dated practitioner’s order, and pertinent information such as found in CMN or DIF. Pertinent clinical information must be included with the request. Include any abnormal findings, prior treatments, and x-ray results if appropriate. The documentation must clearly state why the DME item is required.
• It is the DME provider’s responsibility to gather all required documentation.
• Requests for the renewal of rental items must be received prior to the expiration of active authorization. If the request is not received prior to the expiration of an active authorization, an administrative denial will be issued.
• If your DME request is accident-related, such as MVA with auto or another insurance company involved, insurance information must be faxed to Passport Health Plan along with the original DME request.

Authorization Requirements

Situation	Authorization is Required	Authorization is Not Required
The member has Original Medicare as primary payor and Passport Health Plan as secondary payor
The member has Tricare insurance, the services are covered by Tricare, and Passport Health Plan is secondary payor
In all other instances where Passport Health Plan is the secondary payor
In all instances where Passport Advantage is the primary payor	*Note: You must provide documentation demonstrating why the primary insurance is not covering the services being requested.

Documentation Requirements

• You must have a signed and dated practitioner’s order.

Prosthetics/Orthotics

• All prosthetics and orthotics require authorization.
• Documentation should include member’s present ambulatory status and why member needs the DME item (for example, has outgrown previous orthotic, fracture, foot deformity, etc.)

CPAP/BIPAP

• For CPAP/BIPAP, include current sleep study, current titration study and documentation of symptoms.
• For continued rental, authorization requests must include a compliance report signed by practitioner. (Remember to include compliance information downloaded from machine, if equipment has that capability).
• For purchase, authorization requests must include signed compliance report and order for purchase from practitioner. (Include compliance information downloaded from machine, if equipment has that capability).

Pulse Oximetry Rental

• For pulse oximetry rentals, include documentation of the member’s history, use of home oxygen, recent saturation reading, if oxygen is continuous, prn, and expected duration of need.
• For continuous oxygen rental, authorization requests must include:
  • Current oxygen saturation levels on oxygen
  • Room air if oxygen is prn
  • Clinical update of member’s condition
  • Any apneic episodes since rental authorization

Diabetic shoes

• Authorization requests for diabetic shoes must include a completed, signed and dated “Statement of Certifying Physician for Therapeutic Shoes” from the practitioner who is treating the member for their diabetes.
• If any other provider orders the shoes, the statement noted above must be accompanied by his or her signed order.
• Members are eligible for one pair of diabetic shoes per calendar year.

Enteral Nutrition

• Authorization requests must include:
  • Documentation of why member requires enteral nutrition
  • Method of feedings, such as, bolus, continuous, tube, or ora
  • Current height and weight
  • Weight prior to illness
  • Activity level
  • Type of feeding tube
  • If this is member’s sole source of nutrition
  • Name of product
  • Number of cans taken per day
  • Calories per can
  • Total calories per day practitioner is ordering

Wheelchairs, Power, Manual, Power Operated Vehicles (POV) (Purchase)

• Authorization request must include:
  • All requests for purchases of Wheelchairs and POV's must be accompanied with a physcial/occupational evaluation other than manual wheelchairs K0001, K0006, and K0007 where no evaluation is required.
  • Distance the member is able to walk with or without assist device (i.e. cane or walker).
  • Strength and functional ability of member, upper and lower extremity, ROM, ability to complete ADL’s.
  • Neurological or other limitations that preclude the use of POV over the alternative of a power w/c.
  • Member’s cognitive ability to safely operate a POV or power w/c.
  • Member’s current height and weight.
  • Diagnoses that are associated with the limitations.
  • If home is accessible for DME item requested.
  • For power wheelchair request, please include why the member cannot operate a POV.

Manual Wheelchair (Rental)

• Authorization request must include:
  • All requests for a manual wheelchair other than K0001, K0006, and K0007 must be accompanied with a physical/occupational evaluation.
  • Duration of need, along with signed and dated practitioner’s order.
  • Distance member is able to walk with or without assist device (i.e. cane or walker).
  • Strength and functional ability of member, upper and lower extremity, ROM, ability to complete ADL’s.
  • Member’s current height and weight.
  • Diagnoses associated with the limitations.
  • If home is accessible for DME item requested.

External Continuous Infusion Insulin Pump

• Authorization request must include:
  • 60-day glucose log, testing time, glucose reading, how much insulin was given, and the number of injections per day
  • Name of insulin the member is using.
  • How long the member has been diabetic
  • Current A1C, c-peptide level with fasting blood sugar obtained at same time of c-peptide level
  • Documentation that the member has completed a comprehensive diabetic education program