19 Reserve for Local Use – what is the use

Not required unless otherwise noted.

Durable Medical Equipment (Repairs):
If the repair does not require prior authorization, enter the following
information:
• the name of the person who requested the repair;
• the date of the request and a specific description of the equipment
malfunction;
• a list of procedures and parts used to complete the repair;
• the cost of each procedure and part; and
• the time required to complete the repair.
If there is not enough space in this field, submit an attachment with
the claim containing the above-mentioned information.