CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

DMEPOS Prior Authorization Request Form and Instructions

A faxable prior authorization request form and instructions for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) requests to Neighborhood Health Plan of Rhode Island; used by ordering and servicing providers to submit clinical and administrative information supporting medical necessity for HCPCS-coded items.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDMEPOS Prior Authorization Request Form and Instructions

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFax the completed form and required clinical documentation, including Certificate of Medical Necessity and face-to-face notes as applicable, to 1-248-844-3824 to request prior authorization for HCPCS-coded DMEPOS items.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1fax number to submit requests

Requiredmember and provider fields marked required

Standard/Expedited/Post-Servicerequest priority types available

Multiplerequest types

Certificate of Medical Necessityclinical documentation requested

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDMEPOS Prior Authorization Request Form and Instructions

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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Coverage and Submission Requirements

Administrative coverage submission requirements

Administrative instructions and required supporting documentation to establish medical necessity for consideration of DMEPOS items.

ALL of the following

Submit the completed DMEPOS Prior Authorization Request Form via fax to 1-248-844-3824.
Include ALL clinical information and supporting documentation to support medical necessity for each HCPCS code requested.
Include a Certificate of Medical Necessity and face‑to‑face documentation/notes as applicable.
Include applicable additional documentation (select ONE or more):
- Single Case Agreement (SCA).
- Equipment repair details including manufacturer, model number, warranty information, and date of purchase.
- Over‑Quantity request documentation, including medical necessity justification for each HCPCS code requested.
- Authorization date extension with requested extension date.
- Code and/or quantity change documentation specifying the code change and quantity change.
- Primary insurance information; if item is not covered by primary insurance, submit the denial letter/documentation.
Be aware that receipt of an authorization does not guarantee payment; payment is contingent on medical necessity, member eligibility on date of service, covered benefits, provider contracts, correct coding, billing practices, and claim processing requirements.

Codes, Quantities, and Item Details

HCPCS / CPT mapping and item detailmixed

HCPCS

Form requests medical necessity support for each HCPCS code requested; includes fields to map HCPCS/CPT, ICD-10 diagnoses, rental/purchase indicators, quantities, manufacturer and model information.

Quantity per month

Field purposeField provided on the form to specify the quantity per month for purchases (applies to HCPCS/CPT line items)

Location on formListed in the Additional Information section tied to each HCPCS/CPT line: 'Quantity per month for purchases'

UseEnter the number of units requested per month for purchased (NU) items to support medical necessity and authorization review

How Providers Should Submit Requests

Documentation Required

Submission Instructions

Please fax the completed form and all required clinical documentation (including Certificate of Medical Necessity and face-to-face notes when applicable) to 1-248-844-3824. To prevent delays, complete the form in its entirety and include documentation supporting medical necessity for each HCPCS code requested.

Fax number: 1-248-844-3824
Include: Certificate of Medical Necessity; Face-to-Face documentation; all clinical notes supporting each HCPCS code

Prior Authorization

Request Priority and Expedited Criteria

Select the request priority below. Expedited (urgent) requests may only be initiated by the Member, Member Representative, or the treating physician and only when applying the standard timeframe could seriously jeopardize the member's life, health, or ability to regain maximum function. Post-service requests require the date of service to be provided.

Standard Request

Key Definitions

Single Case Agreement (SCA)

TermSingle Case Agreement (SCA)

Form indicatorThere is a checkbox in the Additional Information section to designate a request as a Single Case Agreement (SCA)

Associated documentationInclude supporting clinical and administrative details when SCA is selected (e.g., manufacturer/model, medical necessity) as applicable

Expedited Request

DefinitionExpedited Request: an organization determination that may be requested when applying the standard timeframe could seriously jeopardize the member's life, health, or ability to regain maximum function.

Who may requestMember, Member Representative, or Physician may request expedited processing.

Documentation Required

Request Type and Supporting Documentation

Indicate the type of request and attach all applicable supporting documentation. For recertification, provide the current authorization number. For Out-of-Network or Over-Quantity requests, include medical necessity documentation for each HCPCS code. Use this area to flag Single Case Agreements, equipment repairs, authorization date extensions, code/quantity changes, and other payer/primary insurance details (include primary insurance denial when item not covered by primary).

New request
Recertification — include Current Authorization #________________
Out of Network
Over-Quantity — include medical necessity for each HCPCS code
Single Case Agreement (SCA) — attach SCA documentation
Equipment Repair — include manufacturer, model #, warranty, date of purchase
Authorization Date Extension — include requested extension date
Code and/or quantity change — specify code change and quantity change
Other primary insurance — indicate and submit denial letter/documentation if item not covered by primary