Payer Names and IDs
Virginia Medicaid
Payer ID 1 and 8
Physician's order expired for T4535 on 06/05/2025
What is No Valid ppwk on file
Actions taken: Confirm what is needed with the customer and request paperwork.
Medicare
Doctor of medicine / Doctor of osteopathy (including osteopathic practitioner) - must be licensed to practice medicine and surgery / Doctor of dental surgery or dental medicine / Doctor of podiatry / Doctor of optometry / Physician assistant / Nurse Practitioner / Clinical Nurse Specialist
LOMN
What is Letter of Medical Necessity? Document that must be typed on a doctor's letter explaining the need for an overage or combination of HCPCs usually not shipped together. Usually needed before requesting a PAR
Payer : Virginia Medicaid
HCPCs: T4525, T4535
T4525 - 180
T4535 - 180
Bluecross Blue Shield of Tennessee
1700
Physician's Order on file but not returned for T4524 with effective date: 07/02/2025
What is we have requested ppwk but it has not been returned by the doctor.
Action taken: Check Medidoc to see if doc has been returned, since last Medidoc note. If yes send to MDA to review, If no send to Doc team
Virginia Medicaid
Physician (MD) / Doctor of osteopathic medicine (DO) / Nurse practitioner (NP) / Physician assistant (PA)
MED RECS
What are MEDICAL RECORDS (Chart notes) -
These are chart notes from the patients last office visit. They contain information pertaining to the customer condition, and are used by the plan to determine, usage and need. Sometime needed before a PAR, sometimes needed on their own.
Payer: Horizon NJ Health
HCPCs: T4525, T4543
T4525 - 300
T4543 - 300
Medicare
13,225,226,230,1782,2237
Prior Authorization not on file for T4530
We have not requested a PAR, and quantities indicate one is needed.
Actions taken: Check payer reqs. Do all HCPCs for this payer require a PAR. If yes, confirm items and quantities, and request a new PAR and new LOMN/MED RECS, if payer requires. If no, ship the allowable and request a new PAR and new LOMN/MED RECS, if payer requires
Blue Cross Blue Shield of Tennessee
ยท Physician (MD) / Doctor of osteopathic medicine (DO) / Nurse practitioner (NP) / Physician assistant (PA)
PO
Physician's Order - prescribing document
a medical professional's written or verbal instructions for a patient's care, treatment, or management.
Kind of a nationwide document, used for supplies covered by Medicare and some state level payers
Payer: Horizon NJ Health
HCPCs: T4525, T4535, A4554
T4525 + T4535 - 300
A4554 - 300
508
CareSource OH MCO
CMF7-BG20 is discontinued
Hover over the line item and look in "Comments" for alternate SKU or product team notes, inform the customer, update the order and save to the template
Horizon NJ Health
Physician (MD, DO, DPM, etc.) / Physician assistant / Nurse Practitioner
CMN
Certificate of Medical Necessity / (Also includes TITLE XIXs for Tx) prescribing docs.
an official document from a physician or other healthcare provider, stating that a patient needs specific medical equipment, supplies, or services due to a diagnosed medical condition
Each state has its own specific requirements for what information needs to be included on a CMN.
Payer: Tennessee Medicaid
HCPCs: A4335, T4541, T4524, T4535, A6250
No allowables. HCD is enrolled with Tennessee Medicaid. However, Tennessee Medicaid covers DMEPOS through Managed Care plans only. HCD is contracted with the following Managed Medicaid plans in Tennessee:
2165
Horizon NJ Health
CRD701-BG20 is not covered
1. The item is not covered by the plan. or
2. The Insurance is missing or incorrect on the order
3. Not tied to the correct payer
If 1., Advise the customer, remove the item and continue with the order
If 2., Document the customer insurance information and assign the order to verification to add and check the insurance. Advise customer to call back in 24-48 hours
If 3., reach to Cat Mgmt to correct
Humana Kentucky
Physician (MD) / Podiatrist / Optometrist / Dentist / Advanced Practice Registered Nurse (APRN) / Physician assistant (PA) / Chiropractor
PAR
Prior Authorization Request - (comes from the insurance)
a process where a health plan needs to approve a medical service or prescription before it's covered. This can be triggered by going over the allowable or exceeding a specific dollar amount. In some instances a plan may require a Prior Auth for all items regardless of quantity
Payer : Virginia Medicaid
HCPCs: T4525, T4535, T4541, A4927, E0325
Either
T4525 -180 / T4535 -180 / A4927 -2 / E0325 -1
or
T4541 - 180 / A4927 -2 / E0325 -1
( # Denotes T4541 and T4542 are not covered in conjunction with any absorbent product.)