Suppliers request DEEOIC prior authorization for durable medical equipment on this form when an energy employee needs equipment for an accepted condition. Each service line gives a CPT or HCPCS code, units, a rental or purchase modifier, cost and, for rentals, duration. The treating physician's prescription and letter of medical necessity are required attachments, so the clinic's documentation underpins the request even though the supplier files it.
The DME provider or supplier completes the form. The treating physician supplies the prescription and letter of medical necessity required in Part E, and the supplier adds how the equipment meets that prescription.
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Durable Medical Equipment Authorization Request
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Usually the DME supplier, as the rendering provider with an OWCP provider ID. The treating physician's role is the prescription and letter of medical necessity, which must be attached. DEEOIC warns that failing to include supporting documentation may delay processing or lead to denial.
Service lines take CPT or HCPCS procedure codes with units, a rental or purchase modifier and total cost. Diagnosis codes go in D1, up to four, using ICD-9 only for dates of service before October 2015 and ICD-10 for later dates.