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 (Monday-Friday, 8 a.m.-5 p.m.) by contacting Apria Healthcare at 1-888-452-4363. The equipment company will not accept direct orders from providers unless our offices are closed. This service is available for all of the Washington region.

Items typically required after-hours include:

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

Other items may also be available.

DME service delivery standards

Our contracted durable medical equipment (DME) services providers are key members of our members' health care team, coordinating services with other Kaiser Permanente providers, such as nursing homes, home health agencies and area hospitals. These providers procure high quality, state-of-the-art DME that ensures the safety of our members. To that end, the DME provider delivers only the DME authorized by the Kaiser Permanente and will bear the cost of any DME, other than that which was authorized, which is delivered and used by a Kaiser Permanente member.

The DME provider will report hazardous situations or medical problems immediately to the referring Kaiser Permanente physician. The DME provider will train members and their family how to operate, care for, and maintain the DME safely and effectively, and provider a copy of all applicable warranties of equipment provided. If necessary, the DME provider will also provide training for specified Kaiser Permanente staff as well.

To ensure the safety of the member, the DME provider will ensure the equipment provided will be free of defects in materials and workmanship and will perform preventive maintenance on all DME. If DME requires repair, adjustment or otherwise malfunctions, the provider will pick up the defective equipment within twenty-four (24) hours of notification and repair it, adjust it, or provide an equivalent substitute. Patient safety is our highest priority, which will guide the provider in determining the appropriate response time for DME repair. In cases where patient safety may be jeopardized, repair or substitution of equipment will be completed as soon as practicable. If, however, the repair is non-urgent, the provider will establish cost estimates in advance of repair and coordinate with Kaiser Permanente for approval to repair or for authorization to replace the DME.