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DME Preauthorization Request Checklist TIP: Waiting can make the process go faster! Wait to submit your preauthorization request until you have all information available. Submitting everything with the initial preauthorization request can help you avoid denials, delays, and requests for additional information: Quick List Preauthorization Request Form Certificate of Medical Necessity (CMN) Written Prescription Patient’s medical records with details such as: Diagnosis (if part of discharge plan, include the admitting diagnosis) Patient history and physical exam findings Progress notes Medication list Wound or incision/location Current detailed invoice listing all requested equipment [Only needed if DME Supplier submitting the
preauthorization request.] Detail Descriptions of What Is Needed Preauthorization Request Form Certificate of Medical Necessity The Requesting Physician, not the DME supplier, is responsible for completing the CMN form for all prescribed DME items. The CMN may, however, be submitted by the Requesting Physician, discharging facility, or DME supplier. TIP: A preauthorization request submitted without a CMN will be denied for lack of information. Waiting to submit the preauthorization request until this is ready will save time and reduce rework. Filling out the CMN form involves: • Certifying the patient’s need. The treating physician must certify in writing the patient’s medical need for equipment and attest the patient meets the criteria for medical devices and/or equipment. • Issuing a plan of care. The treating physician must issue a plan of care for the patient that specifies: – The type of medical devices, equipment and/or services to be provided – The nature and frequency of these services EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC and Health Insurance Plan of Greater New York (HIP) are EmblemHealth companies.
EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. EMBMBFRM61476DME_PreauthorizationRequestChecklist 7/23 (Continued)

EmblemHealth accepts any of the standard CMN forms provided by the Centers for Medicare & Medicaid Services (CMS). These forms can be found on the forms section of the CMS website. Providers must complete Section B of the forms accurately and clearly and transfer adequate notation into the patient’s chart to corroborate the answers supplied on the CMN form. Note: For home oxygen therapy procedures, current blood gas levels or oxygen saturation levels must be noted in the
CMN form. Written Prescription To initiate coverage of DME, the Requesting Physician must issue a prescription, or other written order on personalized stationery, which includes: • Member’s name and full address • Provider’s signature (Signature stamps are not acceptable.) • Date the provider signed the prescription or order • Description of the items needed • Start date of the order (if appropriate) • Diagnosis • A realistic estimate of the total length of time the equipment will be needed (in months or years) Electronic requests for DME preauthorization should be accompanied by a fax containing the written prescription and any applicable CMN forms. Medical Records