DMEPOS Prior Authorization Request Form - Complete and Fax to 833-678-0223

Sep 17, 2026

DMEPOS Prior Authorization Request Form collects member and requester details, including date of request, standard versus urgent request information, contact information, and member demographics and location where DMEPOS will be used. The form captures ICD-10 diagnosis codes, DMEPOS provider identifiers (NPI and Tax ID), ordering provider information, and a detailed HCPCS line list with modifiers, units requested, delivery status, and dates. It also includes processing guidance, confidentiality and legal disclaimers, and notes that authorization receipt does not guarantee payment.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

DMEPOS Prior Authorization Request Form

Request Information

Member and Requester Information

Provider and Ordering Provider Details

HCPCS Item Request Table

Additional Information and Disclaimers

DMEPOS Prior Authorization Request Form FOR FASTER AUTHORIZATION, PLEASE VISIT: [https://providers.carelonmedicalbenefitsmanagement.com/postacute/](https://providers.carelonmedicalbenefitsmanagement.com/postacute/) PLEASE FAX THIS FORM ALONG WITH INFORMATION TO: 833-678-0223 REQUIRED | Questions? Call 844-411-9622 | | | --- | --- | | Date of Request: | Standard Request:
Urgent Request:
Note: Expedited organization determinations (urgent requests), can only be requested by the Member, Member Representative, or a Physician and only if applying the standard timeframe could seriously jeopardize the life or health of the member. (See CMS regulation: 40.8) | | Note: To prevent delay in processing your request, fill out this form in its entirety with all applicable information. Include ALL clinical information and other supporting documentation with this form to support each HCPCS requested. | | | Member Information | | | First Name: DOB: Member ID:
Middle Name: Ht: ft in Health Plan:
Last Name: Wt: lbs | | | Member Location | | | Location the DMEPOS will be used
Home Assisted Living Group Home Other(explain) | | | Your Information | | | Name: Secure Fax:
Phone Number: Ext: Email: | | | ICD 10 Diagnosis Code(s) (at least one required) | | | Primary | | | DMEPOS Provider | | | Enter NPI and Tax ID of provider dispensing DMEPOS product.
DMEPOS Provider NPI: DMEPOS Provider Tax ID: | | | DMEPOS Provider Name: Phone: Secure Fax:
Physical Address: City, State,Zip: | | | Ordering Provider (Physician/Treating Practitioner) | | | Ordering Provider (Physician/Treating Practitioner) NPI: | | | First Name: Phone: Street Address:
Last Name: Secure Fax: City, State, Zip: | | | HCPCS | Modifier (NU, RR, UE if applicable) | Brief Description | \# Units Requested 1 unit = 1 month for rentals | Delivered? List Yes or No | Date Delivered | Request Start Date | | --- | --- | --- | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Additional Information: Disclaimer: Please note that receipt of an authorization does not guarantee or authorize payment. Payment for covered services is contingent upon various factors including medical necessity, member eligibility on the date of service, covered benefits, provider contracts, correct coding, billing practices, as well as claim processing requirements. CONFIDENTIALITY NOTICE: This fax message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information or may otherwise be protected by law. Any unauthorized review, use, disclosure, or distribution is cprohibited. If you are not the intended recipient, please contact the sender by fax and destroy all copies of the original message and any attachment thereto.

FAQs

How are standard and urgent requests handled on this form?

The form distinguishes Standard Request and Urgent Request. Expedited determinations for urgent requests can only be made by the member, member representative, or a physician, and only when the standard timeframe could seriously jeopardize the member’s life or health.

What information is required to support each requested HCPCS?

The form requests all applicable clinical information and supporting documentation and includes an HCPCS table where each requested item lists modifier, brief description, units requested, delivery status, date delivered, and request start date.

Does receiving authorization guarantee payment for covered services?

No. The disclaimer states that receipt of authorization does not guarantee or authorize payment; payment depends on factors such as medical necessity, eligibility, covered benefits, contracts, correct coding, billing practices, and claim processing requirements.

Sep 17, 2026

Uploaded by Bill Black