Transcription of Durable Medical Equipment (DME) Authorization Request
1 Durable Medical Equipment (DME) Authorization RequestPlease type/print legibly and fax completed form to: Commercial Utilization Management at 1-866-558-0789 OR Submit online Authorization requests via Availity anytime day or night*Member Name _____Date of Birth _____Member ID Number_____Diagnosis with Diagnosis Codes _____Contact Name _____Phone _____Fax Number _____Ordering Physician _____Physician Address _____Physician/Provider #/NPI# _____Physician Phone Number _____Fax Number _____Date of Order or Certificate of Medical Necessity _____DME Supplier _____DME Supplier Address _____DME Supplier # _____NPI# _____DME Supplier Phone _____Fax Number _____Start Date _____Duration _____Equipment Codes RequestedCode Quantity Purchase or Rental Monthly Rental price OR Purchase price1. _____ _____ o o $ _____2. _____ _____ o o $ _____3. _____ _____ o o $ _____4. _____ _____ o o $ _____5. _____ _____ o o $ _____6. _____ _____ o o $ _____Clinical InformationInclude a list of all pertinent information (Attach records if needed):Please allow up to 15 days for a determination.
2 * Contact the eBusiness Marketing team for all your Availity registration and training needs by calling 423-535-5717 option 2 or emailing BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association18 PED308814 (05/18)1 Cameron Hill Circle, Suite 0017 Chattanooga, TN
