Diabetic Blood Glucose Monitoring Supplies Prior Authorization
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This document governs prior authorization and clinical information collection for diabetic blood glucose monitoring products and supplies requested for Highmark Blue Shield members; it affects prescribing providers requesting coverage for these products.
No material clinical or coverage changes in this revision.
Coverage Criteria
General coverage criteria
Coverage determination is based on completion of the form demonstrating ALL applicable criteria are met, including diagnosis, treatment details, and clinical need.
See form items 1,2,2a,3,4,9,10,11 and Prior Authorization instructions
Hypoglycemia / Insulin-treated criteria
Additional criteria apply for members with problematic hypoglycemia or who are insulin-treated.
See form items 5,6a,7a,7b,8; include supporting chart notes
Special needs
Special monitoring needs may qualify a member for specific supplies when documented.
See form items 12 and 13; include supporting chart notes
The form does not list any explicit exclusions. Coverage determination is driven by completion of the clinical questions on the prior authorization form and meeting the stated medical necessity requirements rather than by a separate exclusion section on the form.
The form includes an operational notice that payment is subject to member eligibility and that authorization does not guarantee payment. Providers should verify member eligibility and benefits prior to assuming payment will be made.
Coding and Thresholds
Provider Actions and Documentation Requirements
Prior authorization required — fax or mail completed form with clinical documentation
A completed prior authorization form and supporting clinical documentation must be submitted for requests for diabetic testing supplies. Fax the completed form and all clinical documentation to 1-866-240-8123 or mail the form as instructed (120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222).
- Submit a separate form for each medication when applicable.
- Prescribing physician (PCP or Specialist) should generally complete the form.
Document prior product trials and failures with chart notes
Provide a list of any other products the member has tried and failed and include chart notes documenting previous failures, intolerance, or contraindications.
- Use the Product History section to list prior products tried.
- Attach chart notes that support prior product failures, intolerance, or contraindications.
Attach chart notes to support clinical history and training
Include pertinent chart notes to support clinical indications such as history of poorly controlled diabetes, problematic hypoglycemia, insulin pump use, training, or other reasons documented on the form.
- If history of poorly controlled diabetes is reported, include chart notes (form item 3).
- Attach documentation of training, insulin pump use, or other clinical details requested on the form.
- Fax the completed form and all clinical documentation to 1-866-240-8123.
Authorization does not guarantee payment; payment depends on member eligibility
Payment is subject to the member's eligibility; an authorization does not guarantee payment even if prior authorization is obtained.
- The submitting provider certifies the information is true and that the requested services are medically indicated, but payment depends on member eligibility.
Background
The prior authorization form collects clinical details needed to determine medical necessity for blood glucose monitoring supplies. Required information includes whether the member has a diagnosis of diabetes mellitus, pregnancy/gestational diabetes status, a history of poorly controlled diabetes (with a request to include chart notes when applicable), and whether the treating practitioner has confirmed that the member or caregiver has received sufficient training on use of the requested product. The form also requests prior product history and asks providers to include chart notes to document prior failures, intolerance, or contraindications.
Definitions
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