Prior authorization for durable medical equipment

Most but not all Kaiser Permanente plans provide some coverage for durable medical equipment (DME). Plans may have variable levels of coverage, deductibles, copayments, or coinsurance.

To determine coverage, use the Eligibility Inquiry tool . To see medical necessity review criteria, see clinical review criteria. Contact the Provider Assistance Unit at 1-888-767-4670 for information about coverage and medical necessity criteria.

Billing and payment

Kaiser Permanente does not reimburse for items or services that are considered inclusive of, or an integral part of, another procedure or service. Sources of commonly accepted standards include The Centers for Medicare and Medicaid Services (CMS), The National Uniform Billing Committee (NUBC) and the National Correct Coding Initiative (NCCI). Billing of durable medical equipment must be in accordance with applicable laws and regulations and industry standard practices.

Ordering process

You can make DME prior authorization requests by contacting Review Services or using our Referral Request tool .

To expedite patient care, please check the CPT code in the PreAuthorization Code Check Tool. The tool will inform you if an authorization is needed. If it is needed and there is documentation indicated for the review, please attach those records to your referral request in Affiliate Link.

Effective Aug. 1, 2013, Kaiser Permanente expanded its partnership with Apria Healthcare to an exclusive provider relationship for certain core DME services. Under this relationship, Apria provides a list of core services (PDF) for Kaiser Permanente HMO members.

Once your order is received, Review Services will:

• Verify patient eligibility and benefits.
• Review guidelines and authorize or deny requests based on established Medicare or health plan criteria.
• Review and determine cost-effectiveness of equipment purchase versus rental.

For coordination of equipment delivery and pickup, contact the vendor.

Urgent after-hours needs

You may obtain urgent and emergent equipment after normal business hours by contacting Apria Healthcare at 1-800-562-6505 or a branch office found on its website. The equipment company will not accept direct orders from providers unless our offices are closed. This service is available in Western Washington only.

Items typically required after-hours include:

• Hospital beds
• Oxygen
• Walkers
• Wheelchairs
• Commodes
• Breast pumps
• Nebulizers

Other items may also be available.