Durable Medical Equipment Management

Effective November 1, 2014 the Alliance is  introducing two new changes to our management of Durable Medical Equipment (DME). The changes apply to members assigned to an Alliance directly contracted provider, Children First Medical Group (CFMG), and Community Health Center Network (CHCN). Members assigned to Kaiser Permanente Medical Group are excluded from these changes, as Kaiser's DME policies will apply to those members.

  • California Home Medical Equipment (CHME) will perform prior authorization reviews and supply medical equipment for the majority of DME services, which includes respiratory therapy items, medical supplies, enteral nutrition, ambulatory aids and specialty rehabilitation services.
  • Alliance Utilization Management department will perform prior authorization reviews for the remaining medical supply items not available through CHME (such as orthotics and prosthetics, pharmacy/infusion supplies, hearing aids, and other miscellaneous items). These services, if approved, will be authorized to an alternate vendor.

Our new DME management program will:

  • Drive quality improvement
  • For the majority of DME items, enhance provider service through better coordination and management of supply delivery and medical necessity determinations through a single vendor channel
  • For remaining DME items, providers only have to submit authorizations to the Alliance rather than multiple medical groups, thereby improving provider coordination
  • Quicker delivery of DME supplies from CHME

Prior Authorization Requirement

All new and renewal DME services still require prior authorization and will be reviewed by CHME or the Alliance Utilization Management Department. Whether an authorization is reviewed by CHME or the Alliance is based on the HCPC code.

A complete list of services requiring authorization and the corresponding UM processor is available here. The list will indicate the corresponding UM processor for each service at the procedure code level.

The Alliance can only authorize medical supply items not available through CHME to a select group of vendors. Please submit orders to a designated vendor as specified for each item category. Otherwise, the Alliance Utilization Management Department will modify the provider’s request to a preferred vendor. 

  • Effective November 1, 2014, DME services managed by CHME are excluded from the Alliance’s retrospective authorization policy which allows for authorization submission up to 30 days after the date of service.  The Alliance will not grant an authorization for these services unless the service was rendered for an emergency medical condition, the emergency need is explained, and the authorization request is clearly marked “RETRO.”   These requests will be reviewed on an individual case basis. The Alliance will issue an administrative denial for retrospective authorizations which do not meet these requirements.
  • Failure to obtain a prior authorization for DME services by the servicing provider (unless the service was rendered for an emergency medical condition) will result in claim non-payment and will become the provider’s liability. As the claim is non-payable due to provider non-compliance, this will not be considered a “Non-Covered Service”. Our members may not be balanced billed in these situations, whether or not a "member consent form" for Non-Covered Services has been signed.

     

 

 

Initiating an Authorization

Authorization requests should be submitted to either the Alliance or CHME through the contact numbers below using the standard Alliance Authorization Request form. Providers can also obtain status updates on a submitted authorization using the numbers below.  Both CHME and the Alliance are open for phone calls from 8:30 a.m. to 5:00 p.m., Monday through Friday.

 

Method of Submission

For Services Provided & Managed by CHME For Services Not Provided by CHME & Managed by the Alliance

Phone

800-906-0626

650-357-8550

510-747-4540

Fax

844-583-4049

650-523-4508

855-891-7174

Email

aaorders@chme.org (to submit authorizations)

aaquestions@chme.org (for questions)

 

Not available at this time

 

Online

Coming soon...

Not available at this time

 

The following minimum information will be required to initiate an authorization:

  • Patient information
    • Name
    • Address and phone number
    • Date of birth
    • Member Identification number
  • Ordering provider information
    • Name
    • Address and phone number of practice
    • National Provider Identification (NPI)
  • Requested HCPC code(s) and name(s)
  • Diagnosis code(s)
  • Any clinical information pertaining to the requested service

An authorization/notification number, along with any quantity or date limits, will be given for all authorizations that are consistent with evidence-based clinical guidelines.