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Durable Medical Equipment
Alaska Medicaid Provider Training
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Disclaimer
The information contained in this presentation was current at the time it was written. It was prepared as a tool to assist providers and is not intended to be all inclusive, grant rights, impose obligations, or function as a stand-alone document. Although every reasonable effort has been made to assure the accuracy of the information within the presentation, the ultimate responsibility for understanding Medicaid program regulations lies with the provider of services.
The State of Alaska – Department of Health and Social Services – and Conduent, Incorporated employees and staff make no representation, warranty or guarantee that this compilation of information is error-free and/or comprehensive and will bear no responsibility or liability for the results or consequences of the use of this guide.
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Overview
• Provider Enrollment • Member Eligibility • Durable Medical Equipment Services • Service Authorization Requirements • Claim Submission • Additional Information
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Provider Enrollment
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Medical Supplier Enrollment
Durable Medical Equipment (DME) providers must be enrolled in Alaska Medicaid to be reimbursed for covered services or items rendered to eligible Medicaid members. Providers must: • Have and maintain a valid business license issued under AS 43.70 and 12 AAC 12 • Have and maintain an active Medicare DMEPOS enrollment concurrently with Alaska Medicaid enrollment
− A DME provider that fails to maintain Medicare enrollment for the duration of their Medicaid enrollment may be disenrolled
• Enroll as a DME provider and maintain a DME enrollment if providing: − Durable medical equipment, − Medical supplies, − Respiratory therapy assessment visits, − Home infusion therapy services, or − Non-customized fabricated orthotics
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Home Infusion Therapy Enrollment
Home Infusion Therapy (HIT) providers must be enrolled in Alaska Medicaid to be reimbursed for covered services or items rendered to eligible Medicaid members. Providers must: • Have a valid business license issued under AS 43.70 and 12 AAC 12 • Hold an active pharmacy license under AS 08.80 • Meet the guidelines for pharmacies and pharmacists under 12 AAC 52.400 – 12 AAC 52.440 • Have and maintain an active Medicare DMEPOS enrollment concurrently with Alaska Medicaid enrollment
− An HIT provider that fails to maintain Medicare enrollment for the duration of their Medicaid enrollment may be disenrolled
• Complete, sign, and submit a Home Infusion Therapy Addendum • Meet all participation requirements for a Durable Medical Equipment (DME) provider and maintain a separate
Alaska Medicaid DME enrollment
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Respiratory Therapy Enrollment
Respiratory therapy providers must be enrolled in Alaska Medicaid to be reimbursed for covered services or items rendered to eligible Medicaid members. Providers must: • Hold an active national registry number and certificate from the National Board for Respiratory Care (NBRC) • Enroll as an individual Alaska Medicaid provider and maintain an affiliation with an enrolled durable medical
equipment supplier group
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Provider Participation Responsibilities All providers enrolled in Alaska Medicaid are responsible for adhering to program participation requirements. DME providers must: • Verify that the recipient is eligible to receive the product • Furnish orientation and training to the recipient regarding the proper use of the item; providers must submit proof of
this training to Alaska Medicaid upon request • Maintain proof of receipt for items supplied to recipients; must submit proof of receipt to Alaska Medicaid upon
request • Document and maintain records of a recipient's request for a refill, including the quantity of items that the recipient
requests and the recipient possesses • Supply no more than what the recipient needs for a 30-day period • Accept returns of any substandard item that does not function in a manner that meets the prescribed need or
specifications • Upon request, provide proof, in the form of copies of letters, logs, or signed notices, that the recipient has been
supplied with the item’s warranty information
Additionally, medical suppliers must review the continued medical necessity of DME or supplies at least annually. More frequent reviews may be required depending on the item prescribed.
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Recordkeeping
Recordkeeping requirements are documented in the Individual Provider Agreement and Tax Certification and Group Provider Agreement and Tax Certification
• Although most recordkeeping requirements are consistent for all providers, some requirements are provider-type specific
− In addition to all other Medicaid program recordkeeping requirements, all pharmacy records must include both proof of counseling and proof of receipt as required in 7AAC 120.110
• Providers must maintain complete and accurate clinical, financial, and other relevant records to support the care and services for which they bill Alaska Medicaid for a minimum of 7 years from the date of service
• Providers are subject to audits, reviews and investigations
Providers must ensure their staff, billing agents, and any other entities responsible for any aspect of records maintenance meet the same requirements.
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Member Eligibility
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Member Eligibility
Always verify member eligibility by using one of the following options: • Request to see the member's eligibility coupon or card that shows the current month of eligibility; photocopy for your
records • Call Automated Voice Response System (AVR):
− 855.329.8986 (toll-free) • Verify via Alaska Medicaid Health Enterprise website
− http://medicaidalaska.com • Fax complete Recipient Eligibility Inquiry Form - General
− 907.644.8126 • Submit a HIPAA compliant 270/271 electronic Eligibility Inquiry transaction • Call Provider Inquiry
− 907.644.6800, option 1 or 800.770.5650 (toll-free), option 1, 1
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Member Eligibility Cards & Coupons 1. Member Name 4. Eligibility Code
2. Member ID 5. Eligibility Month/Year
3. Date of Birth 6. Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
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Member Eligibility
Eligibility Code Category
11 Pregnant Woman (Alaska Healthy Baby Program)
20 No Other Eligibility Codes Apply
21 Chronic and Acute Medical Assistance Coverage Only (CAMA)
24 300 percent Institutionalized
30 Adults with Physical and Developmental Disabilities (APDD), Waiver Only
31 APDD, Waiver Medical
34 APDD, Waiver Adult Public Assistance (APA)/Qualified Medicare Beneficiary (QMB)
40 Alaskans Living Independently (ALI), Waiver Only
41 ALI, Waiver Medical
44 ALI, Waiver APA/QMB
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Member Eligibility
Eligibility Code Category
50 Under 21
51 Juvenile Court Ordered Custody of Health and Social Services
52 Transitional Medical Assistance
54 Disabled/Supplemental Security Income (SSI) Child
69 APA/QMB - Dual Eligibility
70 Intellectual and Developmental Disabilities (IDD), Waiver Only
71 IDD, Waiver Medical
74 IDD, Waiver APA/QMB
80 Children with Complex Medical Conditions (CCMC), Waiver Only
81 CCMC, Waiver Medical
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Durable Medical Equipment Services
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DME Covered Services
Alaska Medicaid covers durable medical equipment (DME), medical supplies, and prefabricated off-the-shelf orthotics if the item(s) are: • Prescribed by a physician, physician assistant, or advanced practice registered nurse enrolled in Alaska Medicaid
and acting within the scope of their license • Prior to the receipt of a prescription order, a face-to-face examination as defined under 42 CFR 440.70(f) and 42
CFR 410.38 must occur no more than six months prior to the start of services and must be related to the primary reason that the recipient requires the DME
• Appropriate for use in the recipient’s home, school, and community • Not provided by, or under arrangements made by, a home health agency • Granted a service authorization, if required
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DME Covered Services (cont.)
Covered services continued: • Dispensed pursuant to a valid prescription order • Dispensed up to a 30-day supply within each 22-day period • Reviewed for continued medical necessity • The least expensive product(s) available
More costly DME may be covered if the provider submits documentation with the claim demonstrating that a less expensive product is not available to meet the medical needs of the recipient. Providers may request a higher reimbursement for a state-based rate by submitting the Alternate Reimbursement Rate Request form.
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Labor and Repair Parts
Alaska Medicaid covers labor and repair parts for damaged items if all warranties are expired, the cost of repair is less than half of the cost of a new item and the repair has a warranty for a minimum of 30 days. The provider billing for repairs must provide the following documentation: • A statement signed by the recipient or the recipient's authorized representative that describes the cause for and
nature of the repair • A description of the item being repaired and its serial number, if available • The beginning and end dates of warranty coverage, if available • Documentation for labor charges that includes the amount of time spent on the repair, rounded up to the nearest
quarter hour, and the hourly rate charged for the repair • An itemized list of parts used in repair and associated costs
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Item Purchase
The department may authorize the purchase of new DME, medical supplies, prosthetics, orthotics, and prefabricated off-the-shelf orthotics. The department will review the length of need and cost of an item before authorizing the item for purchase or rental. • Purchased items become the property of the member for whom they were purchased • The enrolled provider shall:
− Transfer ownership of the item, including any warranty, to the member − Provider appropriate documentation if the items was previously used
• Capped rental items are considered purchased after 13 months of continuous rental or when 100% of the purchase cost has been paid, whichever occurs first. − Ownership, including warranty and titles, must be transferred on the 1st day after 13 months of rental or after
100% of the purchase cost has been paid
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Item Rental
The department will review the length-of-need and cost of an item before approving durable medical equipment rentals. • Reimbursement is per the established rental period: daily or monthly
• Rental fees cover necessary repairs, return shipping, and item maintenance
• For items identified as capped rentals on the fee schedule, rentals are limited to the lesser of 13 months or the full purchase price of the item
− Ownership, including warranties and title, must be transferred to the member after 13 months of continuous rental
• When total rental payments reach the purchase price, except for items that must be continuously rented, repair is covered after 60 days or when the warranty expires, whichever is later
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Rental Period
• Rental periods begin when the member first receives the rental item
• Rental periods end when there is an interruption in rental use of 60 consecutive days or more days, plus remaining days in the rental month in which use ceases
• Rental periods ending due to an excessive interruption will require a new prescription order and a new service authorization request prior to a new rental period
• A 13-month continuous rental period for capped rental items is not interrupted if:
− Member changes their address temporarily or permanently
− An addition/modification is made to an existing item because of a substantial change in the member’s medical need
Note: Rental period for the original item continues and a new rental period begins for the added item
− An item is replaced with a different, but similar, item with the same HCPCS code during a current rental period
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Item Rental (cont.)
• Rental period interruptions affect reimbursement as follows: − For temporary interruptions that continue beyond the end of the month in which use ceases, payment will be made
for the month in which use ceased, but additional payments will not be made until use resumes – a new date of service will be established when use resumes
− Unreimbursed months for temporary interruptions do not count toward a capped rental period − If an interruption reaches or exceeds 60 consecutive days or if the authorized rental period expires during the
interruption, a new authorization request must be submitted with the reason for the interruption in order for a new rental period to be approved
• If an item is modified or replaced with a different item during a current rental period, the rental will continue to be applied against the rental period in place and the payment will be for the least expensive item that meets the member’s medical needs
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Used Item Purchase or Rental
The department may pay for used or refurbished DME at a rate of no more than 75% of the established rental or purchase rate. • Used or refurbished items must:
− Be clean and sanitized − Meet recipient’s current needs − Meet manufacturer’s suggested specifications for new items − Be able to withstand minimum of 3 years of use
• Recipient must acknowledge they are receiving used equipment in writing and provider must maintain documentation
• Provider must bill with modifier UE, signifying used equipment, and retain product serial number in the dispensing record
• If previously used equipment must be replaced before the standard replacement limit is met, provider must replace with new or used equipment at no charge
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Item Replacement
The department may authorize the purchase or rental of durable medical equipment or pre-fabricated orthotic to replace an item if the item to be replaced: • Has been in continuous use by the member for the item’s reasonable useful lifetime • Is not covered by a manufacturer’s warranty • Is lost, stolen, or irreparably damaged (submit explanation of loss or damage with the claim with any supporting
documentation attached e.g., police report for stolen items, insurance claim if damaged in auto accident) • Has not already been replaced within the immediate 3 years due to loss, abuse, or neglect of the product • Is replaced with a like item • If originally rented, the provider replaces the item with a like item and continues renting the replacement in
accordance with item rental regulations
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DME for Members in Long-Term Care
Enrolled providers may be reimbursed for purchase or rental of DME for a member in a skilled or intermediate nursing facility if the equipment is medically necessary for the member’s preparation for discharge or for the actual discharge to home
• Equipment purchase or rental may not be arranged more than 30 days before the scheduled discharge
• Will be authorized only if the equipment is not provided by the long-term care facility
• Trial use of rental equipment may be reimbursed if it is necessary for preparing the member for discharge
Continuous oxygen may be covered for a member in long-term care if the facility is not authorized to provide continuous oxygen
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Incontinence Supplies
Providers must maintain prescription and Incontinence Certificate of Medical Necessity for each recipient. The information must be submitted with any request for service authorization or as requested by the department. Service authorization is required for medical supplies that exceed the maximum units or as indicated on the fee schedule. The department may pay for: • Disposable incontinence products including diapers, liners, underpads, reusable protective underpads, wipes, and
washcloths for members 3 years of age and older if: − The supplies are prescribed by an enrolled physician, physician assistant, or advanced practice registered nurse
on a Certificate of Medical Necessity – Incontinence Supplies − The supplies meet national quality standards − The supplies accommodate a medical condition resulting in bladder or bowel incontinence − The member has not responded to, would not benefit from, or has failed bowel or bladder training
• Skin sealant, skin moisturizer, skin cleanser, skin protectant, skin ointment, skin sanitizer for members with bladder or bowel incontinence
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Enteral and Oral Nutritional Products
DME providers may be reimbursed for enteral and oral nutritional products if those products are: • Prescribed by the member’s attending physician, physician assistant, or advanced practice registered nurse • Certified as medically necessary using the Certificate of Medical Necessity form • Certificate of medical necessity must indicate that sufficient caloric or protein intake is not obtainable through
regular, liquefied, or pureed food
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Respiratory Therapy
• An enrolled DME provider may be reimbursed for respiratory therapy equipment, supplies, and assessment visits if the: − Member is ventilator-dependent − DME provider employs or contracts with a registered respiratory therapist or a certified respiratory therapy
technician − Equipment is not provided by, or under arrangements made by, a home health agency or hospice program
• Assessment visits must be certified as medically necessary using the Certificate of Medical Necessity form − Assessment visits furnished to members receiving hospice care services may be authorized if the visits are
prescribed and continually reviewed by a physician as part of a written hospice plan of care
• Neither a registered respiratory therapist nor a certified respiratory therapy technician may be paid separately for respiratory therapy assessment visits – these providers must enroll as renderers and affiliate to the DME provider
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Home Infusion Therapy (HIT)
• Home Infusion Therapy services may be reimbursed if the services are:
− Ordered by a physician, physician assistant, or advanced practice registered nurse
− Reviewed at least every 60 days by the ordering practitioner to determine ongoing medical need for the service
− Appropriate for use in the member’s home, school, or community • A home infusion therapy period begins the day services are initiated and ends the day services are discontinued
and not anticipated to begin again − Services that begin after a therapy period has ended are considered part of a new therapy period
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Home Infusion Therapy – Skilled Nursing Services
If a HIT provider is also providing skilled nursing ordered by the physician, physician assistant, or advanced practice registered nurse, the skilled nursing visits must be provided in the member’s home. Home infusion therapy providers may be reimbursed for:
• One skilled nursing visit for catheter insertion and patient instruction at: − A hospital on the day of discharge or one day before discharge − A hospital-based infusion clinic or ambulatory surgery center on the day of surgery
• No more than one skilled nursing visit per day, if total cumulative time of the visit, including multiple trips, is 2 hours or less; if cumulative time exceeds 2 hours in same day, each additional hour is paid separately
• A per diem amount, if: − Skilled nursing visit is provided on same day the member received infusion therapy services outside the home and − A physician, physician assistant, or advanced practice registered nurse has ordered additional infusion therapy
services to continue in the home
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Delivery and Shipping
• Enrolled providers may be reimbursed for the reasonable and necessary direct costs of delivery or shipping expenses incurred in delivery of items from the dispensing provider to the member or from the member to the dispensing provider for repair of member owned equipment if: − Member resides outside the municipality where the business of the enrolled dispensing provider is located − Item is unavailable from an enrolled provider where the recipient resides − Cost of shipping home infusion pharmaceutical products exceeds 40 % of the sum of the per diem rate for the
number of days represented in the shipment − Final unaltered purchase invoice price exceeds $250 for a specialized or unique item
• Multiple shipments on the same date of service for a single member must be consolidated into a single shipment where possible − If not feasible, submit total shipping charges for all shipments on a single claim line and attach all shipping
receipts to the claim
Note: The shipping method used must be the most cost effective method available.
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Delivery and Shipping
Alaska Medicaid may cover delivery and shipping charges for: • Shipping methods other than the most cost effective, such as expedited or next day delivery
− Prescribing provider must submit medical justification for the more costly delivery method
• Shipping costs due to member travel for medical, education, or vocational reasons − Prescribing provider must submit documentation supporting member’s reason for travel with claim; documentation
must also include estimated duration of travel
• Shipping costs from the manufacturer to the provider for customized DME repair and replacement parts that are specialized or unique to the member’s equipment and final unaltered purchase invoice price exceeds $250 − Unaltered invoice must be attached to claim
• Shipping costs for a member residing in municipality with an enrolled local DME provider − Dispensing provider must submit documentation attesting that the member has attempted to acquire the item from
the local provider and the item was not available
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Prescription Orders
A prescription order is required for all durable medical equipment (DME), medical supplies, and related items and must contain the following: • Recipient’s name and date of birth • Item being prescribed • ICD diagnosis • Quantity of item being prescribed • Directions or instructions for proper use of the item including the
frequency of use, if applicable • Duration or estimated length of need for the item • Enrolled prescribing provider’s signature and order signature date • Number of refills, if applicable, • and Date of the face-to-face examination
Face-to-Face Encounter Prior to the receipt of a prescription order, a face-to-face examination as defined under 42 CFR 440.70(f) and 42 CFR 410.38 must occur no more than six months prior to the start of services and must be related to the primary reason that the recipient requires the DME.
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Prescription Orders
Prescription orders: • Will not be accepted more than one year from the signature date • May be requested as part of the Certificate of Medical Necessity (CMN) • Must include the prescriber’s hardcopy, original signature or authenticated digital signature from an EHR; signature
stamps or copies of signatures are invalid • A retrospective start date for a prescription order, with current day signature, may be considered on ta case by case
basis.
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Administrative Expenses
The following costs are not separately reimbursable and are considered administrative expenses included in the payment for items and services: • Telephone responses to questions • Mileage • Travel expenses • Travel time • Setting up an item • Installation • Preparation and maintenance of necessary records • Orientation and training regarding the proper use of the item
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Non-Covered Services
Non-covered services for medical suppliers, respiratory therapists, and home infusion therapy providers include, but are not limited to: • Durable medical equipment (DME) provided to a recipient in a hospital, skilled nursing facility (SNF), or intermediate
care facility (ICF) or who is receiving hospice care services except as allowed by federal law • The repair of DME while the recipient is in a SNF/ICF • Medical supplies or respiratory therapy assessment visits related to the treatment of the terminal illness that qualifies
the recipient for hospice care • Repair, return shipping, or preventive maintenance or service of DME that is already included in the rental fee • Repair, return shipping, or preventive maintenance or service of DME without documented medical necessity for the
continued use of the item • Medical supplies that would result in a duplicate reimbursement situation • Medical equipment that Medicare has deemed medically unnecessary for the individual • Respiratory therapy equipment provided by, or under arrangements made by, a home health agency or hospice
program • Enteral and oral nutritional products provided by, or under arrangements made by, a home health agency or hospice
program
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Non-Covered Services
• Shipping costs related to recreational travel • Labor and repair parts if the item is covered under a manufacturer's or supplier's warranty, or if the labor or parts are
necessary to repair an item because of a manufacturer's defect • Labor and repair parts for a rented item; providers must ensure that a rented item functions as intended after the
provider repairs or replaces the item • Purchase of continuous rental items • A single upfront payment for the full cost of an item identified as a capped rental item • Options, supplies, or accessories that are included in the monthly rental payment or covered by the manufacturer’s
warranty • Home infusion therapy services provided to a recipient:
− In a hospital or SNF/ICF − Receiving skilled nursing visits provided by a home health agency − Who received similar services during an outpatient visit on the same day − Receiving hospice care services
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Non-Covered Services
The following services when provided by a home infusion therapy provider: • Routine servicing of an infusion device for equipment included in the per diem payment • Catheter care and maintenance identified as "not otherwise classified" • Nursing services only for insertion of a peripherally inserted central venous catheter (PICC) or a midline central
venous catheter • Nursing services when same-day services are provided by a home health agency or at a hospital or facility during an
outpatient visit • The following items, without a specific dosage timing or quantity: Pain management infusion Chemotherapy infusion Total parenteral nutrition (TPN) Hydration therapy Antibiotic, antiviral, or antifungal therapy Professional pharmacy services • Continuous insulin infusion therapy • After-hours care
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Non-Covered Services
The following services when provided by a home infusion therapy provider (cont.): • Home injectable therapy • Dietitian services • Delivery or service to high-risk areas requiring escort or extra protection • High-technology registered nursing services • Infusion suite services • Home therapy enteral nutrition • Home administration of aerosol drug therapy • Home transfusion of blood products • Home irrigation therapy
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Service Authorization Requirements
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Fee Schedules Fee schedules tell you: • What services are covered • Maximum allowed reimbursement • Additional documentation requirements • Other special considerations
Fee schedules can be found on http://medicaidalaska.com in the Documents & Forms section
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Service Authorization Requirements
A service authorization (SA) must be obtained to receive reimbursement for most DME items. This includes: • Items, services, and supplies requiring an SA per the Alaska Medicaid DME/POS, DME Incontinence, and Home
Infusion Therapy fee schedules • Capped or continuous rental of durable medical equipment (DME) requiring an SA on the applicable fee schedule • Medical supplies that exceed the maximum units or 30-day limit • Customized or optimally configured DME • Items that are identified by miscellaneous HCPCS codes • Respiratory therapy assessment visits for ventilator-dependent recipients • Home infusion therapy services • Enteral and oral nutritional products • Purchase of DME for a recipient in a skilled nursing facility (SNF) or intermediate care facility (ICF)
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Service Authorization Requirements
Services requiring authorization (cont.): • Continuous oxygen for a recipient in a SNF/ICF
• Purchase of DME if the charge to Alaska Medicaid is over $1,000
• Medical supplies and services if the charge to Alaska Medicaid is over $1,000 for a single claim or for a 30-day supply
• Wheelchairs and other DME requiring a service authorization listed on the CMS “Required Prior Authorization List”
• Optimally configured power wheelchairs which require payment under capped rental rules where the DME provider requests direct purchase
• DME provided to a Medicare-Medicaid dual eligible recipient that Medicare has denied
• Replacement item prior to the end of the item’s useful lifetime
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Requesting Service Authorization
Providers must submit a Certificate of Medical Necessity (CMN) form to Conduent for all DME authorization requests. • Must include a prescription order from the enrolled ordering physician, physician assistant, or advanced practice
registered nurse • Attach documentation that the item or service is necessary to treat, correct, or ameliorate a defect, condition, or
physical or mental illness if the recipient is under 21 years of age • For misc. items or optimally configured DME also include:
− Manufacturer information − Item description or number − Global trade item number (GTIN) − Suggested list price − Serial number
• CMN may be used for a prescription order as long as all components of prescription order are included Note: DME providers may not prepare clinical information and clinical assessment of need sections on a CMN containing prescription order.
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Certificate of Medical Necessity (CMN)
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CMN
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CMN
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Service Authorization Requirements
A service authorization (SA) request for incontinence supplies must be submitted on a Certificate of Medical Necessity – Incontinence Supplies form. This form must be completed by an enrolled ordering physician, physician assistant, or advanced practice registered nurse and include: • ICD diagnosis code related to the cause and type of incontinence of the bladder, bowels, or both • Documentation that the recipient has not responded to, would not benefit from, or has failed bowel or bladder
training for recipients ages 3-10 years • Prognosis for controlling incontinence • Item or items to be dispensed • Frequency of incontinence • Duration of need
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Service Authorization Requirements
The CMN – Incontinence Supplies form must also include: • Diuretic or other medications that increase output • Products currently being used • Skin integrity or vulnerability to skin breakdown • Measurements for product size • Quantity of item or items medically necessary • Known allergies to product materials, when applicable • Description of ability to manage incontinence independently or with assistance
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CMN – Incontinence
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CMN – Incontinence
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CMN – Incontinence
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Service Authorization Processing
• When authorization requests are received, the Conduent Service Authorization Department reviews: − Member eligibility and provider enrollment − Prescription order − Requested services and units − Any medical justification and supporting documentation − History of current and previous authorizations, including any service limits
• Authorization is approved, denied, or pended (if additional information is needed)
• The authorization decision is forwarded to provider listed on the authorization request
A signed certificate of medical necessity and all supporting documentation must be maintained in the recipient’s medical records.
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Common Authorization Errors
Common errors made on SA requests include: • No date(s) of service indicated • Invalid procedure codes • Missing attachments • Insufficient details provided • Failure to verify eligibility for the date of service • SA requested for service that does not require SA • Incorrect form used
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Claims Submission
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Claims Submission Methods
There are several billing options for Alaska Medicaid DME providers. • Alaska Medicaid Health Enterprise
• 837P Transaction (electronic claim using billing software) − Companion Guide: http://medicaidalaska.com − Implementation Guide (referred to as TR3): http://www.wpc-edi.com
• Payerpath (electronic claim)
• CMS-1500, Professional Claim Form (paper claim)
DME claims may be billed only after the member receives the product.
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Billing Unpriced Covered DME
Durable medical equipment that is unpriced will be designated as “By Report” on the DMEPOS fee schedule. • Claims for these items must have an unaltered final
purchase invoice attached • Claims for these items that are submitted without an
unaltered final purchase invoice, or with anything other than an unaltered final purchase invoice, will be denied
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Unaltered Final Purchase Invoice
Claims for unpriced durable medical equipment must be submitted with an unaltered final purchase invoice. • Final purchase invoices that contain legible markings will be considered “unaltered” if the markings:
− Were made by the enrolled provider on the original invoice, − Were made as part of their normal business practices, − Appear on both the original invoice and the copy submitted to Alaska Medicaid − Do not remove, erase, redact, omit, or otherwise modify the invoice resulting in information becoming illegible
• The price on the invoice must match the final price paid by the enrolled provider
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Billing Delivery and Shipping Costs
• When the submitted delivery or shipping charges exceed $50, the claim and supporting documents must include: − Recipient’s name − Delivery address − Itemized list of products shipped/delivered detailing:
• Product name • Product identifier • Quantity • Serial number, when applicable
− Shipment and delivery date, − Recipient’s signature with date of receipt, − Total charges minus all discounts, substantiated by a paid shipping invoice reflecting the actual payment
• Submit delivery and dispensing expenses using HCPCS A9999 with modifier CG for reimbursement consideration
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Billing Delivery and Shipping Costs
Claims must be submitted with additional documentation when submitting charges for the following shipping costs:
• Shipping methods other than the most cost effective, such as expedited or next day delivery − Prescribing provider must submit medical justification for the more costly delivery method
• Shipping costs due to member travel for medical, education, or vocational reasons − Prescribing provider must submit documentation supporting member’s reason for travel with claim; documentation
must also include estimated duration of travel
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Billing Delivery and Shipping Costs
Claims must be submitted with additional documentation when submitted charges for the following shipping costs:
• Shipping costs from the manufacturer to the provider for customized DME repair and replacement parts that are specialized or unique to the member’s equipment and final unaltered purchase invoice price exceeds $250 − Unaltered invoice must be attached to claim and include the purchase invoice for the replacement items or repair
and shipping costs; − If the invoice contains one or more additional items, the shipping costs will be determined by calculating the
average shipping cost per item and multiplying by the number of specific repairs specific to the member
• Shipping costs for a member residing in municipality with an enrolled local DME provider − Dispensing provider must submit documentation attesting that the member has attempted to acquire the item from
the local provider and the item was not available
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Billing Home Infusion Therapy
• When billing multiple administered therapies, providers must bill the appropriate per diem code and modifier for the second, third, or subsequent concurrent therapy per the fee schedule
• Drugs for home infusion therapy may be billed as electronic claims − May not include compounding and dispensing fees unless dispensed to a member in a long-term care
facility
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Timely Filing
• All claims must be filed within 12 months of the date you provided services to the patient
• The 12 month timely filing limit applies to all claims, including those that must first be filed with a third-party carrier
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Pricing Methodology
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DME Services and Supplies with Established Rates
Authorized DME, medical supplies, and pre-fabricated off-the-shelf orthotics will be reimbursed at 100% of the current quarter’s Medicare DMEPOS Fee Schedule.
Suppliers may be reimbursed at rates higher than the established state-based rate for more costly DME, orthotics, or supplies; approved requests are reimbursed as follows:
• Actual acquisition costs < $5,000: reimbursement equals actual acquisition cost + 35%
• Actual acquisition costs ≥ $5,000: reimbursement equals actual acquisition cost + 30%
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Alternate Reimbursement Rate Request Form
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Alternate Reimbursement Rate Request Form
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DME Services and Supplies without Established Rates
Items and services without established rates are manually priced based on the submitted unaltered final purchase invoice price plus 35% until a rate is set.
Rates are set for a covered, non-priced, non-miscellaneous HCPCS code using the following methodology:
Median unaltered final purchase invoice price under $5,000:
• Median price of the first 10 claims plus 35 percent if the paid claims were paid to at least two different enrolled providers
• Median price of all claims paid for the item plus 35 percent if 15 or more claims are paid but claims have not been paid to at least two different enrolled providers for the particular HCPCS code
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DME Services and Supplies without Established Rates (cont’d)
Median unaltered final purchase invoice price $5,000 or more:
• Median price of the first 10 claims + 30% if the paid claims were paid to at least two different enrolled providers.
• Median price of all claims paid for the item + 30% if 15 or more claims are paid but claims have not been paid to at least two different enrolled providers for the particular HCPCS code.
When applicable, the maximum allowable rental rate for an un-priced, covered item defined under a non-miscellaneous code is 10% of the rate determined above.
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Miscellaneous DME HCPCS Codes
Covered Miscellaneous HCPCS Codes without Established Rates
• Reimbursed at the unaltered final purchase invoice price plus 20%
• When applicable, the maximum allowable rental rate for an un-priced, covered item defined under a miscellaneous code is 10% of the combined total of the purchase invoice price plus 20%
A generic rate will not be set for miscellaneous HCPCS codes. Future rates may be based off the National Drug Code or other product identifier and require the unique identifier on the submitted claim.
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Price Research Request Form
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Price Research Request Form
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Pricing for DME Rentals
Rental period > or = 30 days
• Monthly rental rate of 10% of allowed purchase rate or
• Rental price listed on the Alaska Medicaid DME/POS Fee Schedule
Rental period < 30 days
• 150% of monthly fee divided by the number of days in the month, times the number of days in the rental period. Payment may not exceed the monthly rate
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Pricing for DME Rentals (cont’d)
Capped Rental
• Items are reimbursed at the rental rate listed on Alaska Medicaid DME/POS Fee Schedule up to the lesser of: − Purchase price of the item or − 13 months of continuous rental
Daily Rental
• HCPCS codes defined as daily rental codes or with a specific daily rate identified on the Alaska Medicaid DME/POS Fee Schedule will pay at the lesser of: − Listed rental price or − Billed rental rate
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Other DME Rates
Labor and Repair Parts
• Reimbursed at the corresponding labor rate listed on the Alaska Medicaid DMEPOS Fee Schedule for each 15 minutes of labor
Used or Refurbished DME
• Reimbursed up to 75% of the set rate for that item
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Pricing for Respiratory Therapy Assessments
Medical suppliers are reimbursed for each respiratory therapy assessment provided to a ventilator-dependent recipient up to $75 per hour.
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Pricing for Incontinence and Skin Care Products
Enrolled dispensing providers are reimbursed for dispensing specific allowed items described by a national drug code (NDC) listed on the Alaska Medicaid DME/POS Fee Schedule up to the maximum allowable quantities and amounts defined on the fee schedule.
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Pricing for Out-of-State DME Services
Items provided to recipients physically located outside the state of Alaska are reimbursed at 100% of the current quarter’s Medicare DMEPOS Fee Schedule for the state where the item or service is provided.
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Pricing for HIT with Established Rates
Home infusion therapy providers receive a per diem rate listed on the Alaska Medicaid Home Infusion Therapy Fee Schedule, determined as follows:
• 100% for the first administered therapy
• 80% for the second concurrently administered therapy
• 75% for the third and each subsequent concurrently administered therapy
Note: The number of per diem payments made for a therapy period may not exceed the number of days authorized on the order or plan of care.
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Pricing for HIT without Established Rates
Home Infusion Therapy Services
• 1-9 billed claims: 80% of billed charges from in-state enrolled providers
• 10 or more claims: 50th percentile of first 10 claims billed
• Payment rates will be established when 10 claims of a specific home infusion therapy service are submitted
Per diem rates may be determined by adding up the costs of providing the following services then subtracting the cost of drugs and skilled nursing services:
• Professional pharmacy services, including drug compounding
• Care coordination
• Clinical monitoring of the recipient
• Purchase or lease of infusion-related equipment and supplies
• Delivery and pickup of infusion-related equipment, supplies, and medications
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Other HIT Services
Home Infusion Therapy Drugs
• Alaska Medicaid reimburses home infusion therapy providers for covered home infusion drugs at the rate determined under 7 AAC 145.400
Skilled Nursing Services
• Providers are reimbursed up to 85% of the RBRVS per visit rate when the only home infusion therapy service being provided is skilled nursing
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Additional Information
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Overpayments & Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate payment for all billed services, including correct member details and services provided. • In accordance with 7 AAC 105.220(e), Alaska Medical Assistance providers have 30 days from the time of payment
to notify the department in writing of a payment error.
• Federal law (42 U.S.C. 1320(d)) requires repayment of overpayments to the department within 60 days of identifying the overpayment.
• Mail the written overpayment notification and a copy of the RA page detailing the overpayment to the address below:
Conduent State Healthcare, LLC
P.O. Box 240807 Anchorage, Alaska 99524-0807
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Accessing Regulations and Statutes
http://www.alaska.gov/
• Click Find State Statutes and Regulations (“How Do I?” Tab under SERVICES)
• Under “Alaska Law Resources”
− Select Alaska Statutes (AS): AS 47.05, AS 47.07
− Select Alaska Administrative Code (AAC)
• Choose “Title 7 - Health and Social Services”
• Choose “Part 8 – Medicaid Coverage and Payment”
• Choose the appropriate chapter by service or topic
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Additional Resources
Alaska Medicaid Health Enterprise website at http://medicaidalaska.com. • Information necessary for successful billing
• Includes provider-specific Medicaid billing manuals and fee schedules You may also call:
• Provider Inquiry − Eligibility only – 907.644.6800, option 1,2 or 800.770.5650 (toll-free), option 1,1,2 − Claim status and other inquiries – 907.644.6800, option 1,1 or 800.770.5650 (toll-free), option 1,1,1
• EDI Coordinator − Electronic transaction assistance – 907.644.6800, option 3 or 800.770.5650 (toll-free), option 1, 4
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