Durable Medical Equipment (DME) Prosthetics

1 1 CUT9216-1E (6/18) Durable Medical Equipment (DME) Prosthetics and Orthotics Authorization Request FormIMPORTANT1. Claims submitted for these benefits are subject to any applicable lifetime maximums, deductions, coinsurances or provisions, as specified in the member s contract. If applicable, benefits issued for requested services will be subtracted from the member s lifetime benefit maximum. Benefit approval is subject to the following conditions: a) member identification number is effective at the time services are rendered, b) requested benefits are available under the member s contract, c) lifetime benefits not When submitting claims for habilitative services, the modifier 96 must be included.

2 When submitting claims for rehabilitative services, the modifier 97 must be included. 3. Please contact the appropriate provider service area to verify member s eligibility and benefits for requested Claim payment for approved services does not indicate payment for future services. All future claims will be evaluated in accordance with the aforementioned benefit approval conditions and the CareFirst and/or CareFirst BlueChoice utilization management review If you have any questions regarding the extent of this authorization, please call 800-334-3427 ext 6425. Calls will be returned within one business fax the completed form to 410-720-3122 or 410-720-3123.

3 Participating Providers: to initiate a request and to check the status of your request, visit CareFirst Direct at PROVIDER INFORMATIONDate of RequestDate of ServiceProvider/CompanyProvider ID #Provider Fax #Provider Telephone #Provider AddressAgency Contact NameMEMBER/PATIENT INFORMATIONM ember NameMember ID #Member Date of BirthProvider NameProvider ID #Provider AddressRequested Equipment /ItemsRent/Purchase ( R or P )HCPC Code(s)Units per Month Diagnosis Code(s) (ICD-10)Previous Authorization #INTERNAL OFFICE USE ONLYP urchase Item(s) Authorization #Valid _____ to _____ Rental Item(s) Authorization #Valid _____ to _____ CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc.

4 And Group Hospitalization and Medical Services, Inc. CareFirst MedPlus is the business name of First Care, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc. and First Care, Inc., are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, of Nondiscrimination and Availability of Language Assistance ServicesCareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex.

5 CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or : Provides free aid and services to people with disabilities to communicate effectively with us, such as:Qualified sign language interpretersWritten information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as:Qualified interpretersInformation written in other languagesIf you need these services, please call you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator by mail, fax or email.

6 If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you. To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this Rights Coordinator, Corporate Office of Civil RightsMailing Address Box 8894 Baltimore, Maryland 21224 Email Address Number 410-528-7820 Fax Number 410-505-2011 You can also file a civil rights complaint with the Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at or by mail or phone Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington.

7 20201 800-368-1019, 800-537-7697 (TDD)Complaint forms are available at BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc.

8 Of Maryland (used in VA by: First Care, Inc.). Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, (12/17) Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates and you may need to take action by certain deadlines. You have the right to get this information and assistance in your language at no cost. Members should call the phone number on the back of their member identification card. All others may call 855-258-6518 and wait through the dialogue until prompted to push 0.

9 When an agent answers, state the language you need and you will be connected to an interpreter. (Amharic) - 855-258-6518 0 d Yor b (Yoruba) t t l ko: k y s y n w f n n pa i ad j t f r . le n w n d t p t o s le n l ti gb gb s n w n j gb d ke kan.

10 O ni t l ti gba w f n y ti r nl w n d r l f . w n m - gb gb d pe n mb f n t w l y n k d d nim w n. w n m r n le pe 855-258-6518 k o s d r n pas j r r t t a fi s f n l ti t 0. N gb t a oj kan b d h n, s d t o f a s so p m gbuf kan. Ti ng Vi t (Vietnamese) Ch : Th ng b o n y ch a th ng tin v ph m vi b o hi m c a qu v . Th ng b o c th ch a nh ng ng y quan tr ng v qu v c n h nh ng tr c m t s th i h n nh t nh. Qu v c quy n nh n c th ng tin n y v h tr b ng ng n ng c a qu v ho n to n mi n ph.