Overview of Prior

Authorizations for Durable

Medical Equipment

Objectives

1

Overview of the Prior Authorization (PA) process for Durable

Medical Equipment (DME)

Learn how to find an enrolled provider

Access and use the Department of Social Services (DSS) Fee

Schedule

Understand documentation requirements and decision

timeframes

Learn how other insurance plans impact the Medicaid PA

process

Review PA Facts

Outline how to access Medicare support for access issues

Overview

All HUSKY Health members are eligible to receive

healthcare goods or services from Connecticut Medical

Assistance Program (CMAP) enrolled providers

Only CMAP enrolled providers will be reimbursed for

goods or services provided to HUSKY Health members

All ordering, prescribing, or referring providers must be

enrolled as either an ordering/prescribing/referring

(OPR) or CMAP provider

Determinations are made on a case-by-case person-

centered clinical assessment of members and their

clinical needs

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Prior Authorization Requirements

Required for the rental and/or purchase of select DME

Requests are reviewed in accordance with clinical criteria,

guidelines, or medical policies

Medical necessity determinations are based upon the clinical

review of submitted case-specific information with consideration

for a person-centered approach

Payment based on the member having active coverage,

benefits, and policies in effect at the time of service

All determinations are made on the basis of medical

necessity and must be in compliance with the Definition

of Medical Necessity, Regulation 17b-259b(a)

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Definition of Medical Necessity

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Section 17b-259b(a)

“Medical Necessity” (or “Medically Necessary”) means those health

services required to prevent, identify, diagnose, treat, rehabilitate, or

ameliorate an individual’s medical condition; including mental illness, or

its effects, in order to attain or maintain the individual’s achievable

health and independent functioning provided such services are:

(1) Consistent with generally-accepted standards of medical

practice that are defined as standards based on:

(A) Credible scientific evidence published in peer-reviewed

medical literature that is generally recognized by the

relevant medical community

(B) Recommendations of a physician-specialty society

(C) The views of physicians practicing in relevant clinical

areas

(D) Any other relevant factors

Definition of Medical Necessity (cont.)

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(2) Clinically appropriate in terms of type, frequency, timing,

site, extent and duration, and considered effective for the

individual’s illness, injury, or disease

(3) Not primarily for the convenience of the individual, the

individual’s healthcare provider, or other healthcare providers

(4) Not more costly than an alternative service or sequence of

services at least as likely to produce equivalent therapeutic or

diagnostic results as to the diagnosis or treatment of the

individual’s illness, injury, or disease

(5) Based on an assessment of the individual and his/her

medical condition

All final determinations of medical necessity must

be based upon this statutory definition

Person-Centeredness

Providing the member with needed information, education, and

support required to make fully informed decisions about his or her

care options and to actively participate in his or her self-care and

care planning

Supporting the member, and their designated representative(s) in

working together with his or her non-medical, behavioral health, and

medical providers and care manager(s) to obtain necessary

supports and services

Reflecting care coordination under the direction of and in

partnership with the member and his/her representative(s) that is

consistent with his or her personal preferences, choices, and

strengths and that is implemented in the most integrated setting

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Finding a CMAP Provider

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Locating a CMAP Provider

Go to www.ct.gov/husky, click “For Providers” then

“Find a Doctor”

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Locating a CMAP Provider (cont.)

Enter information into

“Provider Search”

If you have trouble finding the

right provider, contact

1.800.859.9889

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DSS Fee Schedule

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Locating the DSS Fee Schedule

Go to www.ctdssmap.com

Click on “Provider”

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Locating the DSS Fee Schedule (cont.)

Click on “Provider Fee Schedule Download”

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Locating the DSS Fee Schedule (cont.)

Click on the “I Accept” button at the bottom of the License

Agreement

Choose the desired Provider Fee Schedule

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Navigating the DSS Fee Schedule

The columns on the Fee Schedule are as follows:

If there is a “Y” in the “PA” column, then prior

authorization is required for that item

If a member needs a larger quantity than what is listed

under the “Qty” column (even if there is no “Y” listed),

then prior authorization is required for that item

If an item does not have a HCPCS code, the provider

may submit with a miscellaneous code

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Procedure Code Proc Description Mod1 Mod1 Desc Rate Type Max Fee Effective Date End Date PA Qty

Clinical Documentation/

Medical Policies

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Required Documentation

Prior Authorization Requests

Completed Outpatient Prior Authorization Request Form

Prescription for the goods/services signed by the

ordering physician

Clinical documentation from the ordering physician (or

evaluating therapist, if applicable) supporting the

medical necessity of the requested goods/services

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Prescription

Per Section 17b-262-681(f) of the Regulations of

Connecticut State Agencies, all DME

prescriptions/orders shall include the following:

Member’s name, address, and date of birth

Diagnosis for which the DME is required

Detailed description of the DME item(s), including quantities and

any special option or add-ons

Length of need for the DME use

Prescribing practitioner’s name, address, signature, and

signature date and

NPI number of the ordering, prescribing, referring practitioner

which must be enrolled with CMAP

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Clinical Information Required Reference Clinical Policies for information on specific goods. Visit

www.ct.gov/husky, click “For Providers,” “Medical Management,”

then “Policies, Procedures & Guidelines.”

http://www.huskyhealthct.org/providers/policies_procedures.html

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Medical Policies

Enclosed Bed Systems

External Insulin Pumps

Foot Orthoses

Functional Electrical Stimulation

Hospital-Grade Breast Pumps

Incontinence Supplies

Orthopedic Shoes

Patient Lifts

Hoyer, sit to stand, and fixed ceiling lifts

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Miscellaneous Type Equipment

(E1399)

Standard bathing/hygiene equipment

Custom bathing/hygiene equipment

Stair glides

Alternative positioning devices

Specialty walkers and gait trainers

Specialty beds and mattresses

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Miscellaneous Equipment

Documentation

Doctor’s order or prescription

Therapist evaluation

Results of the equipment trial or simulation

What else was tried or ruled out

Reasons it was ineffective

Will need to identify why less costly alternatives will not work

Home evaluation, if applicable

Home accessibility confirmed

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The Centers for Medicare and

Medicaid Services (CMS)

Face-to-Face Requirements

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Face-to-Face Requirement

Federal law requires a face-to-face visit with an enrolled

physician, physician assistant (PA), or advanced practice

registered nurse (APRN) in addition to the prescription order,

for certain DME ordered on or after July 1, 2017

No Medicaid payment will be issued for certain DME unless a

face-to-face visit with an enrolled physician, PA, or APRN

occurs

For more information: Provider Bulletin 2017-19

DME List of Specified Covered Items 23

Face-to-Face Visit

The face-to-face visit must:

Be related to the primary reason the HUSKY Health member

requires the DME

Occur between the HUSKY Health member and a CMAP

enrolled physician, PA, or APRN

Take place on or before the date of the prescription/order

Not be older than six months prior to the date on the

prescription/order

Be on or before the date of delivery

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Face-to-Face Documentation

This documentation must, at a minimum, include all of

the following:

The clinical findings of the face-to-face visit substantiating the

need for the DME

The primary reason that the DME is required

The name (including either hard copy or digital signature) and

credentials of the physician, PA, or APRN who conducted the

face-to-face visit

The date of the face-to-face visit

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Face-to-Face Special Note

The practitioner who conducts the face-to-face visit does

not have to be the same practitioner who signs the

prescription

However, as required by federal law, both practitioners

must be CMAP enrolled

A new face-to-face visit is required for the following:

All initial orders for the purchase or rental of specified DME

items and/or related supplies

When a member has not had a face-to-face visit within six

months of an initial order for the involved DME items

When there is a change in DME provider

A new face-to-face visit is not required for

replacement/broken wheelchairs

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Rental vs. Purchase

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Rental vs. Purchase

Certain DME items must be rented prior to purchase

Codes listed on the fee schedule that include an “RR”

modifier must be rented

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E0261 Hospital bed semi-electric (head and foot adjustment) with any type side rails w

E0261 Hospital bed semi-electric (head and foot adjustment) with any type side rails w RB

E0261 Hospital bed semi-electric (head and foot adjustment) with any type side rails w RR

E0265 Hospital bed total electric (head foot and height adjustments) with any type sid

E0265 Hospital bed total electric (head foot and height adjustments) with any type sid RB

E0265 Hospital bed total electric (head foot and height adjustments) with any type sid RR

Rental Documentation

Initial face-to-face visit within six months of order (if

HCPCS included on the CMS list):

Must include the medical need for the requested goods OR

Physician progress note along with applicable

supplemental documentation

Prescription dated after the face-to-face visit

Fully completed PA form

Rentals can be authorized for up to three months

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Purchase Documentation

Updated clinical documentation showing the medical

need for continued use of the requested goods:

Letter of Medical Necessity from the ordering practitioner or an

office visit note

A new face-to-face visit will be required if the documentation

submitted is greater than six months old (if HCPCS included on

CMS list)

Original or updated prescription:

Prescriptions for DME are only valid for one year from the

signature date

Fully completed PA form

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Authorization Special Notes

Additional rental periods can be requested if the

member has a short-term need for the equipment:

Example: Member has a four month weight-bearing restriction

An additional 1 month rental can be requested

Purchases for equipment for a short-term need:

If the member does not have a medical need for long-term use,

authorization for a purchase will be denied

Example: Member has a four month weight-bearing restriction with

no other comorbid conditions

It is not medically necessary for this member to have a purchase.

Consideration may be made for a continued rental

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Review Timeframes

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Review Timeframes

All requests for DME are reviewed within 14 calendar days

from the date of receipt

If more information is needed, the clinical reviewer will

contact the provider and the provider is given additional time

to submit the requested information

A decision must be made by the 20th business day from the

date of receipt

If the requested information is not submitted, then this results in a lack

of information denial

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Request Approvals

Approval notifications are given within 24 hours of the

determination

Approval letters are distributed by:

Fax to DME providers

Mail to members

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Request Denials

Verbal notifications provided to DME providers and

referring physicians within 24 hours after a decision has

been made

The verbal notification includes an outline of the appeal

process

Letters are faxed to DME providers and referring

physicians and mailed to members within three business

days from the decision date

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Peer-to-Peer Discussion

After a denial has been issued, Community Health

Network of Connecticut, Inc. (CHNCT) offers a peer-to-

peer discussion to the prescribing physician

This occurs between the prescribing physician and the

physician who rendered the decision

If the CHNCT physician is unavailable, an alternate

physician will perform the peer-to-peer discussion

The peer-to-peer discussion must be initiated by the

prescribing physician within two business days from the

denial notification

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Member Appeal

The HUSKY Health member has the option to request

an appeal, which must be received within 60 days of the

documented medical necessity denial decision date

Appeals rights and procedures are documented on the

medical necessity determination letter sent to the

member

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Provider Appeal

CMAP providers (ordering physician and DME vendor)

have the option to request an appeal, which must be

received within 10 days of the documented medical

necessity denial decision date

Provider appeal procedures are documented on the

medical necessity determination letter sent to the

provider

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Other Insurance

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Commercial Insurance

If a HUSKY A, C, or D member has a commercial plan,

that plan is always primary

Provider Bulletin 2014-24: Authorization is required

when members have other insurance. Effective for dates

of service May 1, 2014 and forward, providers are

required to obtain authorization prior to the service

being rendered when the member has other insurance

and the services require prior authorization

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Commercial Insurance (cont.)

If the primary payer has approved the services, the

authorization is entered strictly for payment purposes

The DME vendor will need to supply a copy of the Explanation

of Benefits (EOB) with the authorization request

If the primary payer has denied the services, the request

will require a full medical necessity review

If the primary payer has not made a determination, a full

medical necessity review will be completed and

coordination of benefits will be applied during claims

processing

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Medicare

For members with Medicare benefits, staff will determine

if the service requested is covered by Medicare

If the service is covered, the requesting provider will be notified

that prior authorization is not required

Part A covers: inpatient care at a hospital, skilled

nursing facility (SNF), and hospice as well as lab tests,

doctor visits, and home health care

Part B covers: a portion of doctor visits, some home

health care, some medical equipment, outpatient

procedures, rehabilitation therapy, laboratory tests, X-

rays, mental health services, ambulance services, and

blood

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Medicare (cont.)

If the service is not covered by Medicare, a full medical

necessity review will be completed

If Medicare denies a service, the request could be

retrospectively reviewed based on that denial

Medicare denial will need to be submitted with the authorization

request

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Prior Authorization Facts

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Prior Authorization Facts

Decisions are made within 14 calendar days if no

additional information is needed

If additional information is needed, a decision is made

by the 20th calendar day

Urgent requests are reviewed within 24 hours

Either to facilitate a discharge into the community or to prevent a

hospitalization

All requests are reviewed on an individual case-by-case

basis

Under Early & Periodic Screening, Diagnostic &

Treatment (EPSDT), all requests must be reviewed for

medical necessity

“Not a covered benefit” is not applicable

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Medicare and Medicaid

Medicaid may cover a non-coded or miscellaneous item.

All reviews are conducted with a person-centered focus

HCPCS codes that end with 99 (E1399, A9999, etc.)

You do not have to receive an approval or denial from

another insurance before Medicaid can review

Review can be done while waiting for other determinations

Equipment that no longer meets the member’s needs, is

broken/damaged beyond repair, or lost/stolen, can be

replaced before the five year “Medicare” timeframe

For Medicare/Medicaid members, the DME vendor must submit

the request to Medicare as well as Medicaid

If Medicaid approves a replacement device, the coordination of

benefits will occur on the claims side, even if Medicare denies

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Medicare vs. Medicaid

Medicare Medicaid

Time limit Will only replace if over 5

years

Each request is reviewed for

medical necessity

Miscellaneous

Codes

Never covered Each request is reviewed for

medical necessity

Bathroom

Equipment

Never covered Each request is reviewed for

medical necessity

Custom

wheelchairs –

SNF

Rarely covered Each request is reviewed for

medical necessity

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Tips for Success

Start the prior authorization process early

CHNCT has a 14-day turnaround time for non-urgent requests

You may submit a request as soon as you have a known

discharge date to avoid a delay

The vendor will request a future date for the authorization

Do not wait for a determination from another insurance

plan

Submit to CHNCT at the same time as you submit to the other

insurance

Coordination of benefits will be completed when claims are

submitted

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Tips for Success (cont.)

Submit all documentation to the DME vendor including

prescription, face-to-face documentation, and therapist

evaluation, if applicable

Respond to request for additional information timely

Maintain copies of all clinical documentation submitted

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Support

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Support

Medicare should be made aware of access to care issues

Call 1.800.MEDICARE (1.800.633.4227) to locate a

supplier, ask a question, or file a complaint

Use the Medicare Supplier Directory to locate a supplier:

www.medicare.gov/supplier

Ask if their supplier accepts Medicare assignment. If the

supplier doesn’t accept assignment, the person with

Medicare could be responsible for paying higher

coinsurance

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Webinars

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PA Webinars

Go to www.ct.gov.husky, click “For Providers,” “Prior

Authorization,” “Prior Authorization Webinars”

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PA Webinars (cont.)

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Questions?

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