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Prior Authorization Update: Durable Medical Equipment Effective October 1, 2017

Date: 08/01/17

Effective for dates of service including and after October 1, 2017, NH Healthy Families will be updating prior authorization requirements from all providers for the following Durable Medical Equipment (DME) codes. Prior authorization can be requested through the Secure Portal or by completing the forms on NHhealthyfamilies.com and faxing the health plan. You can also use the Pre-Auth Needed? tool located on the NH Healthy Families website under Provider Resources to check authorization requirements.

New Codes requiring Prior Authorization Effective October 1, 2017:

Code

Description

C1822

GEN NEUROSTIM HI FREQ RECHARG BATT 

E0766

ELEC STIM CANCER TREATMENT                                             

L1851

KO SINGLE UPRIGHT PREFAB OTS                                           

L1852

KO DOUBLE UPRIGHT PREFAB OTS           

Q4137

AMNIOEXCEL OR BIODEXCEL, 1CM                                           

Q4139

AMNIO OR BIODMATRIX, INJ 1CC                                           

Codes No Longer Requiring Prior Authorization Effective October 1, 2017:

Code

Description

E2294

SEAT, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHI

E2603

SKN PROTECTION WC SEAT CUSHN WIDTH < 22 IN DEPTH

E2604

SKN PROTECTION WC SEAT CUSHN WDTH 22 IN/GT DEPTH      

E2605

PSTN WHEELCHAIR SEAT CUSHN WIDTH < 22 IN DEPTH      

E2606

PSTN WHEELCHAIR SEAT CUSHN WIDTH 22 IN/GT DEPTH      

E2607

SKN PROTECT&PSTN WC SEAT CUSHN WDTH <22 IN DEPTH         

E2608

SKN PROTCT&PSTN WC SEAT CUSHN WDTH 22 IN/GT DPTH                       

E2609

CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION SIZE                         

E2611

GEN WC BACK CUSHN WDTH < 22 IN HT MOUNT HARDWARE                       

E2612

GEN WC BACK CUSHN WDTH 22 IN/GT HT MOUNT HARDWRE                       

E2613

PSTN WC BACK CUSHN POST WIDTH < 22 IN ANY HEIGHT                       

E2614

PSTN WC BACK CUSHN POST WIDTH 22 IN/> ANY HEIGHT                       

E2615

PSTN WC BACK CUSHN POSTLAT WIDTH < 22 IN ANY HT                        

E2616

PSTN WC BACK CUSHN POSTLAT WIDTH 22 IN/> ANY HT                        

E2617

CSTM FAB WC BACK CUSHN ANY SZ ANY MOUNT HARDWARE                       

E2620

PSTN WC BACK CUSHN PLANAR LAT SUPP WDTH <22 IN                         

E2621

PSTN WC BACK CUSHN PLANAR LAT SUPP WDTH 22 IN/>                        

E2622

ADJ SKIN PRO W/C CUS WD<22IN                                           

E2624

ADJ SKIN PRO/POS CUS<22IN                                              

L2112

AFO-FRACTURE/TIBIAL FX ORTHOSIS-SOFT

L7260

ELECT WRIST ROTATOR OTTO BOCK/EQUAL                                    

L7261

ELECT WRIST ROTATOR FOR UTAH ARM                                       

S8262

MANDIB ORTHO REPOSITION DEVICE EACH                                    

We understand the importance of easy access to care, and we are committed to ensuring our prior authorization requirements continue to be appropriate and efficient.  Please contact Provider Services with your questions about authorization requirements at:   1-866-769-3085.