Durable Medical Equipment Prosthetics Orthotics and Disposable Medical

Durable Medical Equipment, Prosthetics, Orthotics and Disposable Medical Supplies DMEPOS 1

Reminder �Our policies are updated on a regular and ongoing basis. To assure you are in compliance with DHCFP’s policies, always use current versions of all policies. ◦ Medicaid Services Manual http: //dhcfp. nv. gov/Resources/Admin. Support/Manual s/MSMHome/ 2

Introduction � 42 Code of Federal Regulations (CFR), Section 1902 of the Social Security Act, and Nevada Revised Statutes (NRS) 422. 2356 with oversight by Centers for Medicare and Medicaid Services (CMS) the DHCFP reimburses for medically necessary equipment and supplies. � Nevada Medicaid covers standard medical equipment that meet the basic medical need of the recipient. � Products must have been approved by the FDA and be consistent with the approved use. * Products or usage that are experimental or investigational and/or items classified as educational or rehabilitative by nature are non covered. 3

DMEPOS � MSM Chapter 1300 ◦ http: //dhcfp. nv. gov/Resources/Admin. Support/Manuals/MSM/C 1300/Chapter 1300/ � Billing Guide PT 33 ◦ https: //www. medicaid. nv. gov/providers/Billing. Info. aspx � MSM Chapter 100 -Medicaid Program ◦ http: //dhcfp. nv. gov/Resources/Admin. Support/Manuals/MSM/C 100/Chapter 100/ � Billing Manual ◦ https: //www. medicaid. nv. gov/providers/Billing. Info. aspx � MSM Chapter 3300 -Program Integrity ◦ http: //dhcfp. nv. gov/Resources/Admin. Support/Manuals/MSM/C 3300/Chapter 3300/ 4

Coverage Areas �Parenteral and enteral nutrition �Medical foods �Oxygen and oxygen equipment �Prosthetics �Orthotics �Disposable medical supply �Mobility 5

Medical Necessity �MSM chapter 100; section 103. 1 ◦ A health care product that is provided for under the Medicaid State Plan and is necessary and consistent with generally accepted professional standards to: diagnose, treat or prevent illness or disease; regain functional capacity; or reduce or ameliorate effects of an illness, injury or disability. The determination of medical necessity is made on the basis of the individual case and takes into account: �Type, frequency, extent, body site and duration of treatment with scientifically based guidelines of national medical or health care coverage organizations or governmental agencies. � Level of service that can be safely and effectively furnished, and for which no equally effective and more conservative or less costly treatment is available. �Services are delivered in the setting that is clinically appropriate to the specific physical and mental/behavioral health care needs of the recipient. � Services are provided for medical or mental/behavioral reasons rather than for the convenience of the recipient, the recipient’s caregiver, or the health care provider. 6

General Information-MSM Durable Medical Equipment (DME) of a medical nature, needed as a 1300 result of a medical condition, and which lasts a considerable time � without significant deterioration and appropriate for use within the home, is covered for eligible recipients. Equipment repairs, or replacement requires medical documentation and is subject to limitations of model, cost and frequency. � Disposable medical supplies are covered for eligible recipients only if they are necessary for the treatment of a medical condition and would not generally be useful to a person in the absence of an illness, disability or injury. � All DMEPOS products and services must be medically necessary, safe and appropriate for the course and severity of the condition, using the least costly and equally effective alternative to meet the recipient’s medical needs. � Deluxe equipment is not authorized when a standard model will meet the basic medical needs of the recipient. The recipient must have a medical need for each component of the item(s) requested. This includes accessory items and features not included in the standard models of the product. 7

Program Integrity - MSM 3300 MSM section 3303. 1. A. 2. h �Soliciting, receiving, offer or pay any remuneration (including any kickback, bribe or rebate) directly or indirectly, overtly or covertly, in cash or in kind, in return for, or to induce any person to make: ◦ 1. Referral of an individual to a provider; ◦ 2. Purchase, order, arrange for or recommend the purchase, order of any item, for which payment may be made under the programs operated by the DHCFP; ◦ 3. Submit bills or requests for payment containing charges or costs that are substantially in excess of customary charges or costs; 8

EPSDT Early and Periodic Screening, Diagnosis and Treatment �Federal program that allows payment for medically necessary equipment and supplies for children under age 21 (up through age 20) �Medicaid Services Manual (MSM) 1500 – Healthy Kids Program: http: //dhcfp. nv. gov/Resources/Admin. S upport/Manuals/MSM/C 1500/Chapter 1500/ 9

Provider Responsibility MSM 1303. 1. B and 1303. 2. B �Ensure appropriate for recipient and recipient’s residence �Provide manufacturer’s invoice for zero rate or non-covered items �Maintain compliance with Board of Pharmacy and MSM Chapters �Maintain records in readily accessible location for at least 6 years from remittance advice MSM section 3303. 1. A. 2. h 10

PA in Emergency Situations: PT 33 Billing guide � Outside of HPES working hours, weekends, on State holidays, dispensing of a 72 -hour supply of those DMEPOS items that require prior authorization (PA) can be allowed only: ◦ When a delay of 24 hours of treatment could result in very severe pain, loss of life or limb, loss of eyesight or hearing, injury to self, or bodily harm to others; and ◦ The treating physician/practitioner indicates a diagnosis that supports the use of the emergency policy. *The supplier must submit the PA the next business day with all required supportive documentation which must include proof of the date and time the order was received by the supplier and documentation to support both in MSM section 1303. 4 11

Expediting DME PA: PT 33 Billing guide *Staff will review the information as soon as possible and expedite review if necessary to avoid delaying movement to a lower level of care, i. e. , discharge from the acute setting to a lower level such as home or to a nursing facility. �Call the Prior Authorization Customer Service unit at (800) 525 -2395 and notify a representative of the need to expedite a PA. ◦ 1. PA number ◦ 2. Rationale for need to expedite 12

Provider Rules and Requirements MSM Chapterinappropriate 100; section 103 �Over-utilization, misuse of medical services must be reported by the provider to Medicaid. �By accepting Medicaid recipients the provider accepts responsibility to make sure recipient receives all medically necessary services. �By accepting Medicaid reimbursement the provider accepts responsibility for their contract and all chapters of the MSM pertaining to their provider type �Required to report in writing within 5 working days any changes in address, ownership, or other info pertaining to recipient of Medicaid funds 13

Dispensing and Delivery of Ongoing Supplies �MSM Chapter 1300, Section 1303. 5 A and B ◦ ◦ ◦ Supplies are dispensed monthly According to physician’s orders Subject to coverage limitations Order valid for 12 months Contact with recipient is required for verification of continued need before shipment or reorder, this must be kept in recipient’s file. ◦ Recipient and provider must have a delivery receipt. 14

Recipient Responsibility �MSM 1303. 1. C and 1303. 4. D ◦ Maintaining equipment, keeping clean, keeping maintenance schedule, safe storage when not in use, for example: �Misuse, abuse or neglect is prohibited. �Returning rented equipment when not needed (recipients can be held financially responsible for not returning equipment). 15

Utilization �MSM 1300 – Appendix B �EVS – Authorization Criteria https: //www. medicaid. nv. gov/ �PT 33 Billing guide https: //www. medicaid. nv. gov/providers /Billing. Info. aspx �Medicare – Noridian Jurisdiction D https: //med. noridianmedicare. com/ 16

Medicaid Program �MSM 100 – Medicaid Program http: //dhcfp. nv. gov/Resources/Admin. S upport/Manuals/MSM/C 100/Chapter 1 00/ �MSM 3100 – Hearings http: //dhcfp. nv. gov/Resources/Admin. S upport/Manuals/MSM/C 3100/Chapter 3100/ 17

Jessica Vannucci Division of Health Care, Financing, and Policy DMEPOS, Social Services Program Specialist II jessica. vannucci@dhcfp. nv. gov (775)684 -3613 Thank you, have a great rest of your day! 18