Prior Authorization
Prior Authorization
Patient has commercial insurance?
We got you covered.
Most Commercial Insurance plans require a prior authorization. Once we have the patient’s demographics, insurance information, prescription and medical records, CGM Monitors will initiate the prior authorization.
Once we have the prescription and the medical records, CGM Monitors will contact the patient’s insurance company and initiate a prior authorization request.
Prior authorization can be used to discourse the need for further clinical patient information. Online adjudication of prescriptions by health plans and prescription benefit management companies (PBMs) has made it more comfortable to administer the DME benefit. However, the information for DME coverage decisions is not always accessible via the online adjudication system. The claims adjudication process does not transmit data such as a patient’s clinical diagnosis and weight, height, laboratory results, non-drug therapy, or over-the-counter medication usage. We can obtain additional information through the prior authorization process. The data is then compared to designated plan coverage guidelines to specify if they can provide coverage.
Medicare Part B
Medicare Part B does not require any authorization for a continuous glucose monitor,
Medicare covers therapeutic continuous glucose monitors such as the Freestyle Libre 2. There is no prior
authorization needed for patient who have Medicare Part B insurance. They do have to meeting the
following requirements set by CMS:
1. Have a face-to-face visit with the ordering provider within the last 6 months and every 6
months.
2. Require frequent adjustment of their insulin
3. They must inject insulin 3 or more times a day
4. Diagnosed with Type 1 or Type 2 diabetes
HMO and PPO
Most HMO and PPO plans require a prior authorization. Once we have the patient’s demographics,
insurance information, prescription, and medical records, CGM Monitors will initiate the prior
authorization. Some plans may require a authorization be initiated by the ordering provider. If the
plans requires that prior authorization to be initiated by ordering provider then we will contract your
physician and inform them that a prior authorization is required and it must be initiated by your
practice.
The final decision is made by your insurance company after a prior authorization is initiated and
supporting documents are provided to the insurance company. The requirements for HMO and PPO
Plans are as follows:
1. Patient must be either Type 1 or Type 2 diabetic.
2. Patient must visit his or her physician within 12 months.
Please note that the patient does not need to frequently adjust insulin dosage. Patient does not have to
be insulin department.
If you would like us to initiate the authorization, please have your physician fax a prescription for
the CGM reader and sensor, medical records/chart notes and a copy of your insurance to (833) 329-
6979/(833) FAX-MY RX. Your doctor can also send us electronic prescriptions/E-scripts however the
medical records/chart notes along with a copy of the insurance card will have to be faxed to us at (833)
329-6979/(833) FAX-MY RX.
