CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Complex Rehabilitation Technology (CRT) Durable Medical Equipment Authorization Request / Coverage Criteria

This document is an authorization request form and instructions for pre-review of Complex Rehabilitation Technology durable medical equipment for Blue Cross Blue Shield of Tennessee members; it affects ordering physicians, DME suppliers, and utilization management staff submitting preauthorization requests.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyCRT DME Authorization Request (coverage criteria / pre-review form)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed pre-review authorization with all member, provider, equipment line-item, and clinical documentation via fax or Availity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1authorization form for CRT DME

fax & onlinesubmission methods

multipleequipment line items fields provided

Coverage and Pre-review Criteria

Pre-review / Coverage determination

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Pre-review submission requirements: All of the following must be provided: member and provider identifiers, diagnosis with codes, complete equipment codes/line items including manufacturer and product numbers, units and billed amounts, and pertinent clinical documentation (attach records).

Reimbursement of billable codes/line items will be based on established/published reimbursement guidelines and/or contracted fee schedules.

Equipment Line Items and Billing Codes

Equipment line items (placeholders)mixed

(line item 1)	Equipment code, Description, Manufacturer, Product Name, Product Number, Units, Amt. to Be Billed
(line item 2)	Equipment code, Description, Manufacturer, Product Name, Product Number, Units, Amt. to Be Billed
(line item 3)	Equipment code, Description, Manufacturer, Product Name, Product Number, Units, Amt. to Be Billed
(line item 4)	Equipment code, Description, Manufacturer, Product Name, Product Number, Units, Amt. to Be Billed
(line item 5)	Equipment code, Description, Manufacturer, Product Name, Product Number, Units, Amt. to Be Billed
(line item 6)	Equipment code, Description, Manufacturer, Product Name, Product Number, Units, Amt. to Be Billed
(line item 7)	Equipment code, Description, Manufacturer, Product Name, Product Number, Units, Amt. to Be Billed
(line item 8)	Equipment code, Description, Manufacturer, Product Name, Product Number, Units, Amt. to Be Billed
(line item 9)	Equipment code, Description, Manufacturer, Product Name, Product Number, Units, Amt. to Be Billed
(line item 10)	Equipment code, Description, Manufacturer, Product Name, Product Number, Units, Amt. to Be Billed

Units/Amount to be billed

Required per line itemExact units and the billed amount (Amt. to Be Billed) must be provided for each equipment line item (per the Equipment Codes Requested fields).

Line-item details to includeFor each code include: HCPCS/CPT code, Description, Manufacturer, Product Name, Product Number, Units, and Amt. to Be Billed.

Purpose for requirementAll codes/line items and required information must be submitted to pre-review for billable codes and coverage determinations for Complex Rehabilitation Technology.

Submission Requirements and Documentation

Prior Authorization

Prior Authorization Required

Authorization submission requirement — pre-review / authorization required. Please complete the Complex Rehabilitation Technology Durable Medical Equipment (DME) Authorization Request form and submit the completed form via fax to Commercial Utilization Management at 1-866-558-0789 or submit online authorization requests via Availity anytime.

Complete all required fields on the form including member name, DOB, member ID, diagnosis with ICD-10 codes, ordering physician and NPI, physician contact info, DME supplier name and NPI, supplier contact info, start date and duration, and requestor contact details.

Billing Rule

Provider: Complete Equipment Line-Item Details

Provider action — ensure all equipment codes/line items to be billed are listed on the form with full detail for each item. Include description, manufacturer, product name, product number, units, and amount to be billed for every code/line item submitted.

List every billable code/line item and include: description, manufacturer, product name, product number, units, and amount to be billed.
Reimbursement will be based on established/published reimbursement guidelines and/or contracted fee schedules.

Note

Provider: Administrative & Billing Information Required

Provider action — include additional actionable information from the form: provide ordering physician and supplier identifiers, addresses, phone and fax numbers, and requestor contact name/phone/fax.

Provide member identifiers, diagnosis codes, and ordering physician and supplier info.
Ensure provider #/NPI and supplier NPI are included.

Documentation Required

Clinical Documentation Required

Clinical documentation requirement — attach all pertinent clinical information and records that support medical necessity. By submitting the request you certify that you have provided all available clinical information pertinent to this request and that the decision should be made based on the submitted information.

Include a list of all pertinent clinical information and attach supporting records as needed.
Contact Availity registration/training: 423-535-5717 option 2 or eBusiness_marketing@bcbst.com for submission assistance.

Denial Risk

Incomplete Submissions Risk Denial

Insufficient information may lead to denial — failure to provide all required information, including complete codes/line items and clinical documentation, may result in denial of the request.

All codes/line items and required information must be provided to pre-review billable codes and obtain coverage determinations.
Incomplete submissions or missing diagnosis codes, line-item details, or supporting clinical records may result in denial.

Key Definitions

Pre-review / authorization definition

DefinitionPre-review / authorization is the process by which the payer evaluates submitted equipment codes/line items and clinical information to determine coverage before billing.

When requiredPre-review/authorization is required for Complex Rehabilitation Technology; submit completed form to initiate evaluation.

OutcomeCoverage determinations are made after pre-review when the required information is submitted; reimbursement will follow established/published reimbursement guidelines and/or contracted fee schedules.

Medical Necessity Assessment

Medical necessity assessment

Medical necessity is assessed based on submitted clinical information and established reimbursement guidelines.

Medical necessity assessment: Decision requires clinical documentation demonstrating the need for the requested complex rehabilitation technology device(s) for the member's diagnosis; include a list of all pertinent clinical information and attach supporting records as needed. By submitting the request, the provider certifies that all available clinical information pertinent to the request has been included.

No device-specific clinical criteria are provided on the form; reimbursement will follow established/published reimbursement guidelines and/or contracted fee schedules.

Reimbursement, Rental vs Purchase Rules

Device category	Reimbursement basis	Rental vs. purchase details
Complex Rehabilitation Technology (CRT) devices	Reimbursement of billable codes/line items will be based on established/published reimbursement guidelines and/or contracted fee schedules.	Specific rental versus purchase rules are not provided on the form; providers must submit all codes/line items and required information to pre‑review to determine whether rental or purchase reimbursement applies.

Replacement Policies

Replacement policy notes

Replacement-specific intervals or rulesThe form does not provide device-specific replacement intervals or replacement rules; reimbursement and replacement determinations will follow established/published reimbursement guidelines and/or contracted fee schedules.

Information required on replacement requestsWhen submitting replacement items, include full equipment line-item details: code, Description, Manufacturer, Product Name, Product Number, Units, and Amt. to Be Billed.

Clinical support for replacementsAttach pertinent clinical records and a list of pertinent clinical information to support medical necessity for replacement devices.

Required Documentation for Pre-review

Step Therapy

Required for pre-review/authorization

For pre-review/authorization submit member demographics, diagnosis codes, ordering physician and supplier details, and a complete list of equipment codes/line items with manufacturer, product name/number, units, and billed amounts.

Background on Complex Rehabilitation Technology

Complex Rehabilitation Technology (CRT) refers to specialized durable medical equipment that requires an individualized assessment to determine medical necessity and appropriate reimbursement. Requests must undergo pre-review/authorization with submission of complete equipment codes/line items and supporting clinical documentation to allow a coverage determination based on the submitted information and established reimbursement guidelines.