Prior authorization request form Form

Questions? Please call the Alliance Provider Services Department Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4540 www.alamedaalliance.org OPUM_DME AUTH UPDATE 01/2023 Important Update: Durable Medical Equipment (DME) Codes that Require Authorization

Alameda Alliance for Health (Alliance) values our dedicated provider partner community. We have an important update we would like to share with you.
Our provider partner satisfaction is a top priority. We are working to improve our Utilization Management and Claims processes to help ensure proper claim payment to our provider partners, and alignment of authorized services. To accomplish this goal, we are reviewing each benefit and we will be sending you updates, as the information is ready to share.
This communication provides an update on durable medical equipment (DME) codes that require prior authorization (PA).
This will affect claims with the date(s) of service starting Monday, April 10, 2023, and onward. Enclosed with this notice is a code-specific list of DME codes that shows which codes require PA. The list can be found on our website at www.alamedaalliance.org/providers/ancillary- network/durable-medical-equipment-dme. Please refer to our website for the most up-to-date information about codes or benefits that require authorization.
In addition to the codes, our claims system will also validate that the claims received match the authorization when authorization is required. The following items will be validated
• Member name
• Provider NPI • CPT and HCPC coding
• Date(s) of service is within the authorized range • Number of units and/or visits
• Place of service matches the site of care submitted on the authorization request form
This update has been validated based on current publishable/billable coding and was confirmed to be covered by the California Department of Health Care Services (DHCS).
Thank you for your continued partnership and for providing high-quality care to our members and the community.

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO A4615 CANNULA NASAL Verify with CHME list first. Unlisted is Alliance or delegate. A4619 FACE TENT Verify with CHME list first. Unlisted is Alliance or delegate. A4620 VARIABLE CONCENTRATION MASK Verify with CHME list first. Unlisted is Alliance or delegate. A5500 DM ONLY CSTM PREP SHOE MX DNS INSRT Verify with CHME list first. Unlisted is Alliance or delegate. A5501 DM ONLY CSTM PREP SHOE MOLD PTS FT Verify with CHME list first. Unlisted is Alliance or delegate. A5503 DM ONLY MOD SHOE/CSTM ROLLER/ROCKER Verify with CHME list first. Unlisted is Alliance or delegate. A5504 DM ONLY MOD SHOE/CSTM W/WEDGE SHOE Verify with CHME list first. Unlisted is Alliance or delegate. A5505 DM ONLY MOD SHOE/CSTM W/MT BAR SHOE Verify with CHME list first. Unlisted is Alliance or delegate. A5506 DM ONLY MOD SHOE/CSTM OFF SET HEEL Verify with CHME list first. Unlisted is Alliance or delegate. A5507 DM ONLY NOS MOD SHOE/CSTM MOLD SHOE Verify with CHME list first. Unlisted is Alliance or delegate. A5512 FOR DIAB ONLY MX DNSITY INSRT PRFAB Verify with CHME list first. Unlisted is Alliance or delegate. A5513 DIA ONLY MX DN INSRT CSTM MLD P F E Verify with CHME list first. Unlisted is Alliance or delegate. A6501 COMPRS BURN GARMNT BDYSUIT CSTM FAB Verify with CHME list first. Unlisted is Alliance or delegate. A6502 COMPRS BRN GARMNT CHIN STRAP CSTM Verify with CHME list first. Unlisted is Alliance or delegate. A6503 COMPRS BRN GARMNT FCE HOOD CSTM FAB Verify with CHME list first. Unlisted is Alliance or delegate. A6504 COMPRS BRN GARMNT GLOV WRST CSTM Verify with CHME list first. Unlisted is Alliance or delegate. A6505 COMPRS BRN GARMNT GLOV ELB CSTM FAB Verify with CHME list first. Unlisted is Alliance or delegate. A6506 COMPRS BURN GARMNT GLOV AX CSTM FAB Verify with CHME list first. Unlisted is Alliance or delegate. A6507 COMPRS BRN GARMNT FT KNEE LEN CSTM Verify with CHME list first. Unlisted is Alliance or delegate. A6508 COMPRS BRN GARMNT FT THI LEN CSTM Verify with CHME list first. Unlisted is Alliance or delegate. A6509 COMPRS BRN GARMNT TRNK WAIST CSTM Verify with CHME list first. Unlisted is Alliance or delegate. A6510 COMPRS BRN GARMNT TRNK ARM LEG OPN Verify with CHME list first. Unlisted is Alliance or delegate. A6511 COMPRS BRN GARMNT LW TRNK LEG OPN Verify with CHME list first. Unlisted is Alliance or delegate. A6513 COMPRS BRN MASK FCE&/NCK PLSTC/EQUL Verify with CHME list first. Unlisted is Alliance or delegate. A6545 GRD CMPRS WRP NONELST BK 30-50 MMHG Verify with CHME list first. Unlisted is Alliance or delegate. A6550 WND CARE SET NEG PRSS WND TX PUMP Verify with CHME list first. Unlisted is Alliance or delegate. Durable Medical Equipment (DME) ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION (PA) PROCEDURE CODES FOR DURABLE MEDICAL EQUIPMENT (DME) Before services are provided, please check: Member Eligibility ▪ Medical Group ▪ Benefit Coverage ▪ Contracted Provider ▪ Medi-Cal Excluded Code Questions? Please call the Alliance Provider Services Department at 1.510.747.4510 Please Note: This list does not include all services. Page 1 of 4 PS_DME PROC CODES REQ PA 03/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO A7015 AREO MASK USED W/ DME NEB Verify with CHME list first. Unlisted is Alliance or delegate. A7020 INTERFACE COUGH STIM DEVC REPL ONLY Verify with CHME list first. Unlisted is Alliance or delegate. A7027 COMB ORAL/NASAL MASK W/CPAP EACH Verify with CHME list first. Unlisted is Alliance or delegate. A7028 ORAL CUSH ORAL/NASAL MASK REPL EA Verify with CHME list first. Unlisted is Alliance or delegate. A7029 NASL PILLOW ORL/NASL MASK REPL PAIR Verify with CHME list first. Unlisted is Alliance or delegate. A7030 FULL FCE MASK POS ARWAY PRSS DEV EA Verify with CHME list first. Unlisted is Alliance or delegate. A7031 FCE MASK INTERFCE REPL FULL MASK EA Verify with CHME list first. Unlisted is Alliance or delegate. A7032 CUSHN NASAL MASK INTF REPL ONLY EA Verify with CHME list first. Unlisted is Alliance or delegate. A7033 PILLW NASL CANNULA TYPE INTF REPL Verify with CHME list first. Unlisted is Alliance or delegate. A7034 NASL INTERFCE POS ARWAY PRSS DEVC Verify with CHME list first. Unlisted is Alliance or delegate. A7035 HEADGEAR USED W/POS ARWAY PRSS DEVC Verify with CHME list first. Unlisted is Alliance or delegate. A7036 CHINSTRAP USE W/POS ARWAY PRSS DEVC Verify with CHME list first. Unlisted is Alliance or delegate. A7037 TUBING USED W/POS ARWAY PRESS DEVC Verify with CHME list first. Unlisted is Alliance or delegate. A7038 FLTR DISPBL W/POS ARWAY PRSS DEVC Verify with CHME list first. Unlisted is Alliance or delegate. A7039 FLTR NON DISPBL POS ARWAY PRSS DEVC Verify with CHME list first. Unlisted is Alliance or delegate. A7044 ORL INTERFCE W/POS ARWAY PRSS DEVC Verify with CHME list first. Unlisted is Alliance or delegate. A7045 EXHALATION PORT REPLACEMENT ONLY Verify with CHME list first. Unlisted is Alliance or delegate. A7046 WATR CHAMB HUMDIFIR USED W/POS ARWA Verify with CHME list first. Unlisted is Alliance or delegate. A9999 DME MISCELLANEOUS Verify with CHME list first. Unlisted is Alliance or delegate. E0170 COMMODE CHAIR SEAT LIFT MECH ELEC Verify with CHME list first. Unlisted is Alliance or delegate. E0171 COMMODE CHAIR SEAT LIFT MCH NONELEC Verify with CHME list first. Unlisted is Alliance or delegate. E0277 POWER PRESSURE-REDUCING AIR MATTRSS Verify with CHME list first. Unlisted is Alliance or delegate. E0424 STATION COMPRS GASOUS O2 SYS RENT; Verify with CHME list first. Unlisted is Alliance or delegate. E0431 PRTBLE GASEOUS O2 SYS RENTAL; Verify with CHME list first. Unlisted is Alliance or delegate. E0433 PORTBL LIQ O2 SYS RENT; HOME LIQUIF Verify with CHME list first. Unlisted is Alliance or delegate. E0434 PRTBLE LIQUID O2 SYS RENTAL; Verify with CHME list first. Unlisted is Alliance or delegate. E0439 STATION LIQUID O2 SYS RENTAL; Verify with CHME list first. Unlisted is Alliance or delegate. E0441 STATIONARY O2 CONT GAS 1 MO SPL=1 U Verify with CHME list first. Unlisted is Alliance or delegate. E0442 STATIONARY 02 CONT LQD 1 MO SPL=1 U Verify with CHME list first. Unlisted is Alliance or delegate. E0443 PORTBL O2 CONTENT GAS 1 MO SPL= 1 U Verify with CHME list first. Unlisted is Alliance or delegate. E0444 PORTBL O2 CONTENT LIQ 1 MO SPL=1 U Verify with CHME list first. Unlisted is Alliance or delegate. E0465 HOME VENT ANY TYPE USED INVASV INTF Verify with CHME list first. Unlisted is Alliance or delegate. E0466 HOME VENT TYPE USED NON-INVASV INTF Verify with CHME list first. Unlisted is Alliance or delegate. E0467 HOME VENTILATOR MULTI-FUNC RESP DVC Verify with CHME list first. Unlisted is Alliance or delegate. Durable Medical Equipment (DME) (cont.) Please Note: This list does not include all services. Page 2 of 4 PS_DME PROC CODES REQ PA 03/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO E0470 RESP ASST DEVC BI-LEVL PRSS CAPABIL Verify with CHME list first. Unlisted is Alliance or delegate. E0471 RESP ASST DEVC BI-LEVL PRSS CAPABIL Verify with CHME list first. Unlisted is Alliance or delegate. E0472 RESP ASST DEVC BI-LEVL PRSS CAPABIL Verify with CHME list first. Unlisted is Alliance or delegate. E0480 PERCUSSOR ELEC/PNEUMAT HOME MODEL Verify with CHME list first. Unlisted is Alliance or delegate. E0482 COUGH STIM DEVC ALTRNAT POS&NEG Verify with CHME list first. Unlisted is Alliance or delegate. E0483 HIGH FREQ CHEST WALL OSC SYS EACH Verify with CHME list first. Unlisted is Alliance or delegate. E0484 OSCILLAT POS EXPIRTORY PRSS NO-ELEC Verify with CHME list first. Unlisted is Alliance or delegate. E0486 ORL DEVC/APPL RDUC UA COLLAPS CSTM Verify with CHME list first. Unlisted is Alliance or delegate. E0561 HUMDIFIR NON-HEAT USED W/POS AIRWAY Verify with CHME list first. Unlisted is Alliance or delegate. E0562 HUMDIFIR HEAT USED W/POS ARWAY PRSS Verify with CHME list first. Unlisted is Alliance or delegate. E0565 COMPRS AIR PWR EQP NOT SLF-CONTAIND Verify with CHME list first. Unlisted is Alliance or delegate. E0570 NEBULIZER WITH COMPRESSOR Verify with CHME list first. Unlisted is Alliance or delegate. E0600 RESP SUCTN PUMP HOME MODEL ELEC Verify with CHME list first. Unlisted is Alliance or delegate. E0601 CONTINUOUS POS AIRWAY PRESSURE DEVC Verify with CHME list first. Unlisted is Alliance or delegate. E0607 HOME BLOOD GLUCOSE MONITOR Verify with CHME list first. Unlisted is Alliance or delegate. E0618 APNEA MONITOR W/O RECORDING FEATURE Verify with CHME list first. Unlisted is Alliance or delegate. E0619 APNEA MONITOR W/RECORDING FEATURE Verify with CHME list first. Unlisted is Alliance or delegate. E0635 PATIENT LIFT ELECTRIC W/SEAT/SLING Verify with CHME list first. Unlisted is Alliance or delegate. E0639 PT LIFT MOVEABLE DISASSMBL&REASSMBL Verify with CHME list first. Unlisted is Alliance or delegate. E0650 PNEUMAT COMPRS NONSEG HOME MODEL Verify with CHME list first. Unlisted is Alliance or delegate. E0651 PNEUMAT COMPRS NO CALBRT GRDNT PRSS Verify with CHME list first. Unlisted is Alliance or delegate. E0655 NONSEG PNEUMAT APPLINC HALF ARM Verify with CHME list first. Unlisted is Alliance or delegate. E0656 SEG PNEUMAT APPLINC W/COMPRS TRUNK Verify with CHME list first. Unlisted is Alliance or delegate. E0657 SEG PNEUMAT APPLINC W/COMPRS CHEST Verify with CHME list first. Unlisted is Alliance or delegate. E0660 NONSEG PNEUMAT APPLINC FULL LEG Verify with CHME list first. Unlisted is Alliance or delegate. E0665 NONSEG PNEUMAT APPLINC FULL ARM Verify with CHME list first. Unlisted is Alliance or delegate. E0666 NONSEG PNEUMAT APPLINC HALF LEG Verify with CHME list first. Unlisted is Alliance or delegate. E0667 SEG PNEUMAT APPLINC COMPRS FULL LEG Verify with CHME list first. Unlisted is Alliance or delegate. E0668 SEG PNEUMAT APPLINC COMPRS FULL ARM Verify with CHME list first. Unlisted is Alliance or delegate. E0669 SEG PNEUMAT APPLINC COMPRS HALF LEG Verify with CHME list first. Unlisted is Alliance or delegate. E0670 SEG PNEU APPL P C INT 2 F LEG TRNK Verify with CHME list first. Unlisted is Alliance or delegate. E0671 SEG GRAD PRSS PNUMAT APPLNC FUL LEG Verify with CHME list first. Unlisted is Alliance or delegate. E0672 SEG GRAD PRSS PNUMAT APPLNC FUL ARM Verify with CHME list first. Unlisted is Alliance or delegate. E0673 SEG GRAD PRSS PNUMAT APPLNC HLF LEG Verify with CHME list first. Unlisted is Alliance or delegate. Durable Medical Equipment (DME) (cont.) Please Note: This list does not include all services. Page 3 of 4 PS_DME PROC CODES REQ PA 03/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO E0747 OSTOGNS STIM NONINVASV NOT SP APPLC Verify with CHME list first. Unlisted is Alliance or delegate. E0748 OSTOGNS STIM NONINVASV SP APPLIC Verify with CHME list first. Unlisted is Alliance or delegate. E0760 OSTOGNS STIM LW INTENS US NONINVASV Verify with CHME list first. Unlisted is Alliance or delegate. E0766 ELEC STM DVC CA TX ALL ACC ANY TYPE Verify with CHME list first. Unlisted is Alliance or delegate. E0783 INFUS PUMP SYSTEM IMPL PROGMMABLE Verify with CHME list first. Unlisted is Alliance or delegate. E0784 EXTERNAL AMB INFUSION PUMP INSULIN Verify with CHME list first. Unlisted is Alliance or delegate. E0785 IMPLANT INTRASPINL CATH PUMP-REPL Verify with CHME list first. Unlisted is Alliance or delegate. E0786 IMPLNT PROGRAM INFUSION PUMP-REPL Verify with CHME list first. Unlisted is Alliance or delegate. E1017 HEAVY DUTY SHOCK ABSORBR MNL WC EA Verify with CHME list first. Unlisted is Alliance or delegate. E1018 HEAVY DUTY SHOCK ABSORBR PWR WC EA Verify with CHME list first. Unlisted is Alliance or delegate. E1231 WC PED SZ TILT-IN-SPACE RIGD W/SEAT Verify with CHME list first. Unlisted is Alliance or delegate. E1353 REGULATOR Verify with CHME list first. Unlisted is Alliance or delegate. E1355 STAND/RACK Verify with CHME list first. Unlisted is Alliance or delegate. E1390 O2 CONC 85%/>02 CONC PRSC FLW RATE Verify with CHME list first. Unlisted is Alliance or delegate. E1391 02 CONC 2 DEL 85%/>02 CONC FLW RATE Verify with CHME list first. Unlisted is Alliance or delegate. E1392 PORTABLE OXYGEN CONCENTRATOR RENTAL Verify with CHME list first. Unlisted is Alliance or delegate. E2100 BLD GLU MON INTEGRT VOICE SYNTHESZR Verify with CHME list first. Unlisted is Alliance or delegate. E2101 BLD GLU MON INTGRT LANCING/BLD SAMP Verify with CHME list first. Unlisted is Alliance or delegate. E2351 PWR WC ACSS ELEC OP SPCH GEN DEVC Verify with CHME list first. Unlisted is Alliance or delegate. E2402 NEG PRSS WND TX PUMP STATN/PRTBL Verify with CHME list first. Unlisted is Alliance or delegate. E2500 SPEECH GEN DEV DIGTIZD</=8 MINS REC Verify with CHME list first. Unlisted is Alliance or delegate. E2502 SPCH GEN DEVC DGTZD>8<= 20 MINS REC Verify with CHME list first. Unlisted is Alliance or delegate. E2504 SPCH GEN DEVC DGTZD>20</=40 MIN REC Verify with CHME list first. Unlisted is Alliance or delegate. E2506 SPCH GEN DEVC DIGTIZD>40 MINS REC Verify with CHME list first. Unlisted is Alliance or delegate. E2508 SPCH GEN DEVC SYNTHSIZD REQ MESS Verify with CHME list first. Unlisted is Alliance or delegate. E2510 SPCH GEN DVC SYNTHSIZD MX METH MESS Verify with CHME list first. Unlisted is Alliance or delegate. E2511 SPEECH GENERATING SOFTWARE PROGRAM Verify with CHME list first. Unlisted is Alliance or delegate. E2512 ACSS SPCH GEN DEVICE MOUNTING SYS Verify with CHME list first. Unlisted is Alliance or delegate. K0455 INFUS PUMP UNINTRPT PARNTRAL MED Verify with CHME list first. Unlisted is Alliance or delegate. K0738 PORT GASEOUS O2 SYS RNTL;HOM COMPRS Verify with CHME list first. Unlisted is Alliance or delegate. Durable Medical Equipment (DME) (cont.) Please Note: This list does not include all services. Page 4 of 4 PS_DME PROC CODES REQ PA 03/2023