Clinician and patient in a wheelchair shaking hands
Stakeholder engagement overview

Successful insurance approvals often involve more than just one medical provider.

When you request durable medical equipment (DME) or supplies, your healthcare providers are there to support you. You, your healthcare provider, and your DME supplier work on the request together. The goal is to have your healthcare insurance provider understand why you need the product and approve your request.

A stakeholder is anyone who helps with your DME request. Each person, or stakeholder, has a specific role in sending information to your healthcare insurance provider.

When you know who is responsible for each part of the process, you can move through the process more confidently. Understanding the process and working as a team can increase your chance of getting the DME or supplies you (or someone you care for) need.

 

In this section, you will learn who is involved, what they do, and how you can work together.

View a full list of what Medicare considers durable medical equipment (DME)1

Durable Medical Equipment (DME) Providers

A DME supplier provides the medical equipment and supplies your healthcare provider orders for you. “DME” stands for durable medical equipment, which is equipment used to help manage health needs.3

In most cases, the DME supplier takes care of the submission paperwork. They work with your healthcare provider and your insurance company to get approval and set up payment.
 

This process often includes gathering and submitting the following:4,5

  • Prescriptions
  • Prior-authorization forms (if required)
  • Medical records
  • Diagnosis codes
  • Letters of Medical Necessity
  • Provider office notes

Since each insurance plan has different rules, make sure you know what documents are needed. Please reach out directly to your DME supplier and/or health insurance provider to understand what specific documents are needed.

The DME supplier manages most of the paperwork, but delays can still occur.

If you are advocating for yourself (or someone you are caring for), you can ask:

  • Has all required paperwork been submitted?
  • Has the insurance company requested more information?
  • Is anything missing that could delay approval?

Keeping in contact with your DME supplier can help avoid
delays.

Learn more about Medicare coverage of DME and other devices3

Healthcare Provider

Your healthcare provider is the doctor or other licensed medical professional who offers healthcare services and prescribes the equipment you need.

Your healthcare provider may be your Primary Care Physician (PCP), Family Physician, Nurse Practitioner (NP), Physician Assistant (PA), or another licensed medical professional. Each state has its own rules about who can prescribe.2

Depending on your needs, your care team may also include specialists. You may be referred to a specialist for a specific product or service. For example, your Primary Care Physician may refer you to a Urologist for urinary products.

Your healthcare provider has an important job in the approval process. They write down your medical needs, decide what equipment is necessary, and provide prescriptions or paperwork when needed.

A prescription for a medical device or supply is written or electronic communication from a licensed healthcare provider for a patient to receive a specific piece of medical equipment. A prescription, along with your healthcare provider’s notes from your medical record, helps ensure the equipment is safe for your condition and is medically necessary.

If you choose to advocate for yourself, you can ask your provider:

  • Is all documentation complete?
  • Do your medical records clearly reflect your needs?
  • Is anything else required before submission?
  • Following up can prevent delays.

 

Detailed definitions2

Specialists

Depending on your needs, your provider may involve specialists.

A specialist is a healthcare provider, such as a doctor, who has completed advanced training in a specific area of medicine to diagnose, treat, and manage complex or focused health conditions.
 

For example, for urinary incontinence or retention products, this may include⁶:

  • A Rehabilitation (Rehab) Physiatrist (a doctor who specializes in physical medicine and rehabilitation)
  • A Physical Therapist
  • An Adult or Pediatric Urologist
  • A Urogynecologist

These specialists may look at your diagnosis, provide supporting paperwork, or confirm that the device is medically necessary.

Healthcare Insurance

Health insurance helps pay for your healthcare costs. An individual or an organization that provides insurance is called an insurer. Health insurance makes it easier to afford the healthcare you need by sharing expenses between you and your insurer.

Different types of health insurance cover, or help pay for, different things. Common types of health insurance include medical insurance (for doctor visits, tests, etc.), prescription drug coverage (medicines prescribed by yourhealthcare provider), dental insurance, and vision insurance.
 

There are several ways that you can buy health insurance. You may have health insurance through:

  • Medicare (often called “Original Medicare”, a federal government program for people who are at least 65 years old or heave certain health conditions)
  • A Medicare Advantage Plan (a way to receive Medicare coverage through private insurance companies)
  • Medicaid (state government-run programs for people with lower incomes)
  • Private, or commercial, insurance (insurance that you buy through your employer, a public health insurance marketplace or exchange, like HealthCare.gov, or directly from a health insurance company)

With your health insurance, you usually have different options when selecting your health insurance plan. Your health insurance plan is a contract between you and your insurer on how costs will be shared. Each plan’s rules are different.

When selecting a health plan, you should consider how the plan will work for your health needs, how it will fit into your budget, and what kinds of healthcare services and providers are covered.

For example, some plans require prior authorization before they will cover a device. Others do not.7 While Medicare typically does not require prior authorization for urinary products, private insurance rules may be different.4,8

If you don’t know your plan’s rules, ask your insurer. Your DME supplier can also help you understand the rules.

 

Knowing the rules early can stop delays.

Please refer to following in this toolkit for more information on healthcare insurance.

Helpful Terms
A Guide to Understanding Your Insurance Coverage

Understanding the Relationship between Stakeholders and the Patient

Schedule a visit with your healthcare provider to talk about the product you’re asking for.5

  • During the visit, you and your provider will decide if you need the product (this is also called medical necessity).5
  • You can also talk about whether you need an in-network Durable Medical Equipment (DME) supplier. Your provider may suggest one, or you can choose one on your own.3

After you choose a DME supplier, contact them to check if the specific product is available and what the next steps should be.

  • If the product is not available, you may need to find a different DME supplier. If the product is available, your healthcare provider may send the prescription directly to the DME supplier or the DME supplier may ask your provider for the prescription.3,4
  • Some products must be prescribed by a certain kind of specialist. For example, your plan may need a prescription from a specialist, such as a urologist or neurologist, instead of your regular doctor or healthcare provider.3,4

 

Some medical practices or hospitals have care coordinators who can help guide you through this process.

This step is mostly handled by your DME supplier and medical team.


Knowing how it works can help prevent delays:

  • The DME supplier first collects the prescription and medical records from your provider or specialist.
  • They then send the request to your health insurance plan so your insurer can review it.4


NOTE: Prior authorization rules depend on your plan. Some plans require a prescription and medical records. Check with your health insurance plan or DME supplier to confirm what your plan needs.


If you don’t know what your health insurance plan requires, contact your insurer or your DME supplier. They can tell you what to do next.

Local Coverage Determinations (LCDs) show what Original Medicare covers in your region.9

Your insurer reviews the request and decides whether to cover the product and how much they will pay.10

  • By law, your health insurance provider must notify you and your medical team of the decision.10
  • The notice will state whether the request is approved or denied.
  • You can stay involved during this stage to help make sure all requested information was sent.
  • If your request is denied, you have the right to appeal.11
  • The next step is to start the insurance appeal process.

 

Medicare

If you have Medicare, check your Medicare plan materials, or contact your insurer, for details about your appeal rights. The plan must tell you, in writing, how to appeal.11 Generally, you can find your insurer's contact information on your plan membership card. You can also ask your healthcare provider or DME supplier for information that can make your appeal stronger.11

Learn more about Medicare Appeals 11

Setting Yourself up for Success

Steps 2 and 3 above mostly happen behind the scenes.

The DME supplier usually sends the required documents for prior authorization.3

To prepare the request, the DME supplier will collect information from your healthcare provider or specialist. This may include diagnosis codes, equipment codes, and a Letter of Medical Necessity, if required.4,5

Even small mistakes, like incorrect codes or missing signatures, can lead to a denial. If this happens, the request may be delayed. The issue may need to be fixed or reviewed in the appeals process.11,12

Tips for Success

  1. If your healthcare provider is unfamiliar with your specialized needs, it may help to ask your specialist to work with your primary care provider.
    This can help ensure your records are complete and accurate.5
    • Your healthcare provider might send the DME supplier medical records, a Letter of Medical Necessity, or chart notes.5 Good communication between them helps make sure nothing is missing.
    • You can help by following up on faxed or electronically sent documents to confirm they have been received. Documents sometimes do not go through. This can cause delays.
       
  2. If possible, try to identify a contact person at your healthcare provider’s office.

    Talking to the same person can keep your care on track and stop delays.

  3. Your specialist is often the most familiar with your medical condition.
    However, they may not know every detail of your daily needs. It may help to explain why a specific DME is important to your quality of life. You can also ask your specialist to share that information with your healthcare provider.

  4. When choosing a DME supplier, it may help to work with a team that communicates clearly.

    A DME team that answers you quickly can help prevent confusion with prior authorization.

  5. It may also help to check in from time to time with your healthcare provider or DME supplier about your prior authorization.

    Checking in can prevent missing information or delays.

 

Staying informed can help you advocate for yourself throughout the process

Documents are provided for educational and informational purposes only and do not guarantee coverage or payment. Coverage and payment policies change over time. The accuracy of the information is not guaranteed and should be confirmed with the payor.

  1. Centers for Medicare & Medicaid Services. Durable medical equipment (DME) coverage. Medicare.gov. Accessed March 16,2025. https://www.medicare.gov/coverage/durable-medical-equipment-dme-coverage
  2. American Academy of Family Physicians. Primary Care. Accessed January 29, 2025. https://www.aafp.org/about/policies/all/primary-care.html
  3. Centers for Medicare & Medicaid Services. Medicare Coverage of Durable Medical Equipment and Other Devices. Accessed January 23, 2025. https://www.medicare.gov/publications/11045-medicare-coverage-of-dme-and-other-devices.pdf
  4. Centers for Medicare & Medicaid Services. Standard Documentation Requirements for All Claims Submitted to DME MACs. Accessed January 23, 2025. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=55426
  5. National Association of Insurance Commissioners. Understanding Health Care Bills: What Is Medical Necessity? Accessed January 29, 2025. https://www.healthcare.gov/glossary/co-insurance/.
  6. National Association for Continence. Finding The Right Specialist for Urinary Incontinence. Accessed January 30, 2025. https://nafc.org/bhealth-blog/finding-the-right-specialist-for-urinary-incontinence https://intermountainhealthcare.org/blogs/what-is-a-specialist-physician-different-types-of-doctors-and-medical-specialists-explained
  7. Centers for Medicare & Medicaid Services. Prior Authorization and Pre-Claim Review Initiatives. Accessed January 30, 2025. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorizationand-pre-claim-review-initiatives
  8. Centers for Medicare & Medicaid Services. Urological Supplies - Policy Article (A52521). Accessed January 30, 2025. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52521
  9. Centers for Medicare & Medicaid Services. Local Coverage Determinations. https://www.cms.gov/medicare/coverage/determination-process/local. Accessed August 29, 2025.
  10. U.S. Department of Health and Human Services. HIPAA Privacy Rule and Access to Health Information. Accessed January 30, 2025. https://www.hhs.gov/hipaa/forprofessionals/privacy/guidance/access/index.html
  11. Centers for Medicare & Medicaid Services. Filing an appeal. Accessed March 1, 2026. https://www.medicare.gov/providersservices/claims-appeals-complaints/appeals
  12. Centers for Medicare & Medicaid Services. Complying with Medicare Signature Requirements. Medicare Learning Network. Accessed January 30, 2025. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-complianceprograms/prior-authorization-and-pre-claim-review-initiatives
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