Durable Medical Equipment, Prosthetics/Orthotics and Supplies (DMEPOS) suppliers follow Medicare guidelines when distributing DMEPOS products for HealthPlus Commercial and Medicare Advantage members.
DMEPOS guidelines are followed for over-quantity requests. Before dispensing items, DMEPOS suppliers must provide to HealthPlus the prescription and related clinical documentation to support the request.
Verify Patient Eligibility
To verify a patient’s eligibility for durable medical equipment (DME) and prosthetic and orthotic (P&O) products and services, please contact the HealthPlus Interactive Voice Response (IVR) at 810-733-1942 or 800-675-2965. You will need to provide the member’s HealthPlus ID number to obtain the HealthPlus coverage dates.
For products or services that do not meet Medicare guidelines, the HealthPlus Prior Authorization and Referral staff will advise the DMEPOS supplier. The supplier should retract the prior authorization request via the PPO patient’s primary care provider.
Request for Prior Authorization
Prior authorization from HealthPlus is required for the following DME items:
- Items that might be considered “deluxe” (e.g., standing wheelchair)
- E1399 NON otherwise classified DME, miscellaneous items
- Non-otherwise Classified DME, miscellaneous items
- Items whose cost is expected to exceed $1,500 for Medicare claims or $3,000 or more for Commercial claims
- CPAP and BIPAP devices
- Bone stimulators
- Insulin pumps
- Continuous glucose monitors
- Gradient compression stockings
To obtain authorization, DMEPOS suppliers must complete and fax the HealthPlus Prior Authorization Request Form, with supporting documentation, to the HealthPlus Referral Department, Attention: DME at 989-799-6471 or 810-230-2086.
*HealthPlus will issue a prior authorization number, the authorization number MUST be included on the claim.
If the service or item is not a covered benefit, the DMEPOS supplier MUST inform the member that the services are not covered by the plan.
Request for Authorization of DMEPOS
Health care providers may call HealthPlus for authorization of a patient’s DMEPOS products and services at 989-799-8723. Required information may also be faxed to the HealthPlus Referral Department at 989-799-6471.
DMEPOS suppliers must submit all physician/patient documentation with the request for authorization.
*HealthPlus will issue an authorization number, the authorization number MUST be included on the claim.
Note: If there is no guideline for over-quantities of supplies billed with a code, please rely on the home health treatment plan, physician order, etc. as evidence of medical necessity to determine quantity and dispense. HealthPlus will review these cases upon retrospective audit.
Certified Medical Necessity (CMN)
If a non-Medicaid member is receiving an over quantity of diabetic supplies or qualifies for replacement of oxygen equipment, a current CMN CMS-854 Continuation Form should be sent by fax to: 810-230-2289.
For more information about the DMEPOS Supplier Authorization Process, please contact the Prior Authorization & Referral Department at 800-942-5974.