REVISED PROCEDURES FOR REQUESTING DURABLE MEDICAL EQUIPMENT PROSTHETICS

(REVISED) PROCEDURES FOR REQUESTING DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES (DMEPOS) VIA MEDICAID

DMEPOS – MEDICAID BENEFICIARIES WHO ARE CLASSIFIED/VERIFIED AS DC MEDICAID MUST HAVE ALL PRIOR AUTHORIZATION REQUESTS FOR DME EQUIPMENT/SUPPLIES PROCESSED THROUGH QUALIS/DC MEDICAID VIA A DC MEDICAID CERTIFIED DME SUPPLIER. 2

DMEPOS – MEDICAID BENEFICIARIES BEFORE PROCEEDING WITH THE INSTRUCTIONS ON THE FOLLOWING PAGES, PLEASE VERIFY THE BENEFICIARY’S INSURANCE COVERAGE VIA DC MEDICAID WEB PORTAL AND/OR VIA INTERACTIVE VOICE RESPONSE (IVR) AT 202 -906 -8319 TO CONFIRM THE TYPE OF COVERAGE AND THAT THE ELIGIBILITY SPAN IS ACTIVE. 3

DMEPOS – MEDICAID BENEFICIARIES • ASK BENEFICIARY WHAT TYPE OF DME SUPPLIES/EQUIPMENT IS NEEDED--YOU SHOULD ALWAYS PROVIDE THE BENEFICIARY WITH THE NAMES AND TELEPHONE NUMBERS OF AT LEAST THREE (3) DC CERTIFIED MEDICAID DME BILLING SUPPLIERS (VENDORS). (A LIST OF CERTIFIED DC MEDICAID BILLING SUPPLIERS IS ATTACHED) • BENEFICIARY MUST OBTAIN FROMPCP(TREATING PHYSICIAN) A PRESCRIPTION, AND A COMPLETED/SIGNED/DATED 719 A FORM (PRIOR AUTHORIZATION REQUEST). SOME DME EQUIPMENT/SUPPLIES WILL REQUIRE A FACE-TO-FACE WITH THE PCP (TREATING PHYSICIAN); • PCP (TREATING PHYSICIAN) NEEDS TO PROVIDE MEDICAL JUSTIFICATION FOR DME SUPPLIES AND/OR EQUIPMENT; AND IN SOME CASES, CHART NOTES MUST BE PROVIDED BY THE PCP (TREATING PHYSICIAN); • BENEFICIARY GIVES THE PRESCRIPTION, 719 A FORM AND MEDICAL JUSTIFICATION FOR DME SUPPLIES AND/OR EQUIPMENT TO A DC MEDICAID CERTIFIED 4

DMEPOS – MEDICAID BENEFICIARIES THE CERTIFIED DC MEDICAID DME BILLING SUPPLIERS MUST SUBMIT THE COMPLETED 719 A FORM (PRIOR AUTHORIZATION FORM), PRELSCRIPTION, MEDICAL JUSTIFICATION AND CHART NOTES (IF REQUIRED) TO QUALIS (DC MEDICAID) VIA QUALIS’ WEBPORTAL OR FAXED TO QUALIS (QUALIS HANDLES ALL DME PRIOR AUTHORIZATIONS FOR DC MEDICIAD-DHCF). NOTE: INCONTINENCE SUPPLIES AND AUTOMATIC BLOOD PRESSURE MONITORS – DO NOT REQUIRE DENIALS FROM MEDICARE – ANY CERTIFIED DC MEDICAID DME SUPPLIERS CAN PROVIDE THESE ITEMS TO BENEFICIARIES WHO QUALIFY FOR INCONTINEENCE SUPPLIES OR AUTOMATIC BLOOD PRESSURE MONITORS; 5

CONTACT INFORMATION FOR ADDITIONAL ANSWERS TO SPECIFIC DC MEDICAID DME QUESTIONS, YOU MAY CONTACT CARMEN KINSEY, ASSOCIATE HEALTH CARE OMBUDSMAN/OUTREACH COORDINATOR, OFFICE OF HEALTH CARE OMBUDSMAN AND BILL OF RIGHTS ON TUESDAYS AND WEDNESDAYS ONLY AT 202 -724 -4207 (OR) YOU MAY CONTACT THE OFFICE OF HEALTH CARE OMBUDSMAN AND BILL OF RIGHTS’ GENERAL TELEPHONE NUMBER AT 202 -724 -7491 (OR) YOU MAY CONTACT THE DEPARTMENT OF HEALTH CARE FINANCE (DHCF/MEDICAID)- MS. 6 HODGE, MANAGEMENT ANALYST/RN AT 202 -442 -4622