Submit clinical documentation in timely manner for faster Medicare Advantage DME authorizations

For durable medical equipment authorization requests, health care providers must submit all required clinical documentation that supports medical necessity and appropriateness for treatment of the member’s diagnosis. Blue Cross Blue Shield of Michigan and Blue Care Network, or our delegated entity, must receive this information with the request to respond within certain time frames required by the National Committee for Quality Assurance and the Centers for Medicare & Medicaid Services.

Blue Cross and BCN contract with Northwood, Inc. and J&B Medical Supply, independent companies, to manage DME authorizations and diabetic supplies for our Medicare Advantage (Medicare Plus Blue℠ and BCN Advantage℠) members.

Northwood, Inc.

Northwood manages authorizations for DME, prosthetics and orthotics, including diabetic shoes and inserts.

With the prior authorization request, include supporting documentation of medical necessity of the prescribed equipment, including prescriptions and letter or certificate of medical necessity in the medical record.

Contact Northwood at 1-800-393-6432 from 8:30 a.m. to 5 p.m. Eastern time Monday through Friday to submit the request. Northwood will identify a contracted DME supplier. Contracted providers can access the Northwood provider portal for authorization submission using our provider portal, Availity Essentials, by following these steps:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces from the Availity^® menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on the Applications tab and scroll down to the Northwood Provider Portal.

J&B Medical Supply

J&B Medical Supply manages authorizations for continuous glucose monitors, insulin pumps and supplies, test strips (if quantity is over standard parameter).

When submitting requests for the supplies listed above, include the following criteria in the medical record:

• Evidence the member has diabetes
• A dated and signed standard written order containing the following:
• Prescribing physician's name, address and telephone number
• Patient's name, address and date of birth
• Diagnosis related to the services or items provided
• Detailed description of the patient's condition to substantiate the necessity for services or items
• Description and quantity of all items, accessories and options ordered
• Estimated duration of need and frequency of use
• Physician's written signature and date. (We don’t accept stamps. Electronic prescriptions are acceptable but must adhere to all privacy, security and electronic signature rules.)

Note: We can’t accept "PRN" (Latin for pro re nata, or as the situation demands) or "as needed" as estimates for supply replacement, use or consumption

• Supporting documentation that the member or caregiver has the necessary training on the diabetic supply or device, met by the standard written order
• Supporting evidence that the member meets Medicare’s Local Coverage Determination for continuous glucose monitoring and/or insulin pumps and supplies 

To request higher quantities of test strips and lancets, include the following documentation:

• Evidence of the member’s in-person practitioner visit to evaluate his or her diabetes control within six months before submitting the request
• Supporting evidence that the member needs a supply quantity that exceeds the usual amount
• Verification every six months that the member’s adherence to a high-use testing regimen requires prescribing quantities that exceed the usual amount

Submit information to J&B Medical Supply by one of the methods below:

• Email: ProviderServices@jandbmedical.com
• Fax: 1-248-255-0157
• Phone: 1-888-896-6233 Monday through Friday from 8 a.m. to 5 p.m. Eastern time

The J&B Medical Supply provider portal is currently in the process of development.

Out-of-state providers

Bill claims for Medicare Plus Blue and BCN Advantage members traveling or residing outside of Michigan through the nationwide network of Blue plan providers via the Blue Cross and Blue Shield Association.

For more information about utilization management, refer to our provider manuals:

• Medicare Plus Blue PPO Provider Manual
• “BCN Advantage” chapter in the BCN Provider Manual (accessed from our e-referral website)