Paula Drever Health Care Compliance Specialist II Virginia Department of Medical Assistance Services

1. 1  Paula Drever Health Care Compliance Specialist II Virginia Department of Medical Assistance Services

2. 2 Objectives To understand and be able to apply medical necessity and covered services criteria as it pertains to Durable Medical Equipment guidelines To be able to correctly complete a CMN/DMAS 352 form and advise others on the completion of the form Understand the preauthorization process and submittal of related forms To understand the purpose and process of utilization review

3. 3 Objectives To correctly utilize the various Medicaid options to verify eligibility How to optimize Medicaid resources Understanding timely filing guidelines How to submit of DME claims, adjustments and voids

4. 4 DME TRAINING AGENDA Introduction Resources DME Covered Services and Limitations Certificate of Medical Necessity (CMN)/DMAS-352 Supporting Documentation and Specific Coverage Criteria Utilization Review Prior Authorization Process Billing

5. 5 Medicaid Resources Websites Emails Important phone/fax numbers

9. 9 FREEDOM OF CHOICE Virginia Medicaid recipients are free to choose a Medicaid enrolled medical equipment and supply provider when medical equipment and supplies are a covered service

10. 10 MEDICAL NECESSITY Medically necessary DME and supplies shall be: Ordered by the physician on the CMN/DMAS-352 Ordered by the MEDALLION primary care physician (PCP) or referred for the service by the PCP A reasonable and medically necessary part of the recipient�s treatment plan

11. 11 MEDICAL NECESSITY Consistent with the recipient�s diagnosis and medical condition, particularly the functional limitations and symptoms exhibited by the recipient Not furnished for the safety or restraint of the recipient, or solely for the convenience of the family, attending physician, or other practitioner or supplier

12. 12 MEDICAL NECESSITY Consistent with generally accepted professional medical standards (i.e., not experimental or investigational) Furnished at a safe, effective, and cost effective level, and Suitable for use in the recipient�s home environment

13. 13 NON-COVERED SERVICES Listed in Chapter IV of the DME Manual Review upcoming manual revision for changes Non-covered items may be explored under EPSDT Lack of a code in Appendix B does not mean the item is a non-covered item

14. 14 CMN - REQUIREMENTS The CMN/DMAS-352 may be completed by: DME Provider Physician Health Care Professional

15. 15 CMN - REQUIREMENTS Refer to the handout for a copy of the CMN/DMAS-352 (8/95 revision) DME and supplies must be ordered by a physician on the CMN/DMAS-352 DME and supplies must be medically necessary to treat a health care condition Alternate versions of the CMN/DMAS-352 are not accepted

16. 16 CMN - REQUIREMENTS The physician must sign and date the CMN within 60 days of the CMN begin service date DMAS will not reimburse the DME provider for services provided prior to the date of the physician�s signature when the signature is not obtained within 60 days of the begin service date (section III of the CMN)

17. 17 CMN - REQUIREMENTS For all DME items/supplies provided, there must be a completed CMN/DMAS-352 The CMN/DMAS-352 allows for up to 12 DME items/supplies to be listed Multiple CMNs must be completed if more than 12 items are ordered Blanket orders, i.e., �Misc. Supplies� are not acceptable

18. 18 CMN - REQUIREMENTS The CMN shall not be changed, altered or amended after the attending physician has signed it If changes are necessary, as indicated by the recipient�s condition, for the ordered DME or supplies, the DME provider must obtain a new CMN/DMAS-352

19. 19 CMN � REQUIREMENTSLength of Certification The CMN shall be valid for a maximum period of six months for Medicaid recipients 21 years of age and younger The CMN shall be valid for a maximum period of twelve months for Medicaid recipients older than 21years of age

20. 20 Length of certification cont'd. DMAS, including preauthorization contractor, has the authority to determine a different length of time needed based upon the medical documentation submitted The validity time of the CMN begins with the Begin Date in Section III. If a begin date is not present it begins with the physician signature The validity of the CMN shall terminate when the recipient�s medical need for the DME or supplies ends

21. 21 CMN VALIDITY EXCEPTION When the DME service is for nutritional supplements, both the Nutritional Status Evaluation Form/DMAS-115 (revision 10/99) and the CMN/DMAS-352 are valid for six months, regardless of the recipient�s age

22. 22 CMN - REQUIREMENTSRETROACTIVE ELIGIBILITY DMAS policy regarding retroactive eligibility is to make an exception to the 60-day physician signature requirement. All remaining criteria, e.g., fully completed CMN, documentation requirements, and specific coverage criteria, must be satisfied in accordance with the State Plan and DMAS policy guidelines

23. 23 CMN � EXCEPTIONSA CMN is not required in the following situations Glucose monitor and diabetic supplies for Pregnant Women - Maternity Risk Screen (DMAS - 16) Medicare Primary- (Unless denied by Medicare)

24. 24 CMN MAINTENANCE Fully completed CMN (and supporting documentation) must be kept in the recipient�s record Copies of CMN and supporting documentation may be sent to a new servicing provider CMN and supporting documentation MUST be maintained for at least 5 years

25. 25 COMPLETING THE CMN DMAS 352 Revised 8/95

26. CMN - SECTION I (Recipient and Provider Data)

28. ICD-9 code is optional Clinical diagnosis-narrative MUST be identified Diagnosis MUST be related to item requested Check appropriate line for date of onset

29. CMN - SECTION III All sections MUST be completed This is the physician�s order for treatment and requests will be pended, and/or retractions will be made upon post payment review, if this section is incomplete

30. CMN - SECTION III (Cont�d) Begin Service Date - Mo/Day/Year Begin Service date of CMN Starts the time clock for CMN validity time frame If blank CMN validity begins with physician signature

31. CMN - SECTION III (Cont�d) HCPCS Code Identify Appropriate HCPCS code using Appendix B Use E1399 if a code is not found in the Appendix B A new CMN is not required if the national code ends during the validity time of the CMN

32. CMN - SECTION III (Cont�d) Item ordered description Must include narrative description Should clearly identify each item ordered

33. CMN - SECTION III (Cont�d) Length of time needed Identify how long the recipient will need the DME service Do not confuse with the CMN validity time

34. CMN - SECTION III (Cont�d) Quantity Ordered x 1 Month Should be based upon the quantity required to carry out the physician�s order for the person List supplies needed for one month including overage and allowables for one month Durable items: complete total of quantity of item needed, e.g. 1, 1 pair, 2.

35. CMN - SECTION III (Cont�d) Quantity/Frequency of Use Justification/Comment Do not use PRN frequency Ranges may be used e.g. 7-8 times per day Frequency validates quantity ordered

36. CMN - SECTION IV � Physician Certification Must be signed and dated by the physician Physician prescription will not be accepted Ordering physician�s name, printed on form Physician provider number is optional Physician telephone number (include area code)

37. 37 CMN Second page If orders or additional information continue on the back page the physician MUST sign and date this page also!

38. 38 PRICINGMarch 19, 2004 Medicaid Memo DME items that have a national code and a DMERC rate, then rate will be the DMERC rate. DME items that have a July 1, 1996 rate, but do not have a national code, then bill the E1399 code (miscellaneous). The rate will continue to be the July 1, 1996 rate.

39. 39 PRICING DME items that have a national code, but do not have a DMERC or a July 1, 1996 rate, then the rate will be the usual and customary charge to the general public Documentation in recipient record must show what this charge to the general public is

40. 40 PRICING DME items that do not have a national code, and do not have a July 1, 1996 rate, then bill the E1399 code (miscellaneous). Rate will be the manufacturer�s cost (to the provider) plus 30%. Documentation showing cost may be in the form of an invoice or estimate

41. 41 Documentation Requirementsfor All DME There must be a fully completed CMN and the documentation must identify: The medical need for DME The diagnosis related to the reason for the DME request

42. 42 Documentation Requirementsfor All DME Must Identify: The recipient�s functional limitation and its relationship to the requested DME How the DME service will treat the recipient�s medical condition How the needs were previously met-identify what changes have occurred which necessitate the DME

43. 43 Documentation Requirementsfor All DME Must Identify: The quantity needed and why that amount is needed The frequency of use The estimated length of use of the equipment Conjunctive treatment related to the use of the DME/supplies

44. 44 Documentation Requirementsfor All DME Must identify: How the service will be used (and is required) within the recipient�s home environment, and The recipient or caregiver�s ability, willingness, and motivation to use the equipment Alternatives explored/tried and describe success/failure

45. 45 Documentation Requirementsfor All DME Assessments/evaluations from other Healthcare Professionals: Nurses Rehabilitative Therapists Rehabilitative Engineers Trained DME Professionals All supporting documentation must be signed/dated by the physician

46. 46 Documentation Requirementsfor All DME Supporting documentation does not replace the requirement of the fully completed CMN The dates of supporting documentation must coincide with the dates of service on the CMN

47. 47 DOCUMENTATION REQUIREMENTS AND COVERAGE CRITERIA In addition to the Medical Necessity guidelines described in Chapter IV, and the previously discussed documentation requirements for all DME, specific medical justification and/or documentation requirements are in place for the following DME:

48. 48 DOCUMENTATION REQUIREMENTS AND COVERAGE CRITERIA  Hospital Beds Patient Lifts Wheelchairs Wound Care Supplies Augmentative Communication Devices Assistive Technology Equipment Blood Glucose Monitors Disposable Incontinent Supplies Disposable Supplies for Infection Control

49. 49 DOCUMENTATION REQUIREMENTS AND COVERAGE CRITERIA Enteral Nutrition Home Infusion Therapy Rehabilitative Equipment Respiratory Equipment Therapeutic Beds and Mattresses TENS Units Orthotics

50. 50 SPECIFIC GUIDELINES FOR WHEELCHAIRS Specialized wheelchairs must have a �hands on� evaluation completed by a health care professional experienced in fitting wheelchairs This evaluation must be signed and dated by the physician

51. 51 SPECIFIC GUIDELINES  FOR WHEELCHAIRS Documentation must include the diagnosis or condition requiring the wheelchair, AND how the requested wheelchair treats the diagnosis/condition Documentation must include the diagnosis or condition requiring each requested component, AND how the requested component treats the diagnosis/condition

52. 52 SPECIFIC GUIDELINES FOR WHEELCHAIRS Identify the distance that the recipient can functionally ambulate and problems associated with ambulation Describe upper and lower extremity strength/weakness Identify tone and spasticity conditions Describe functional head and trunk control

53. 53 SPECIFIC GUIDELINES FOR WHEELCHAIRS Describe recipient�s physical ability/inability for self-propulsion Describe how needs have been met or unmet previously Identify other cost effective alternatives Identify how the requested wheelchair will be used in the recipient�s home environment

54. 54 WOUND CARE SUPPLIES Documentation must include: The related diagnosis, to number of wounds with stages, measurements and description of the wound Who is doing the wound care Wound care supplies used during the course of a home health visit are included in the visit rate

55. 55 SPECIFIC GUIDELINES FOR ENTERAL NUTRITION Coverage is available for nutritional supplements regardless of whether or not the supplement is administered orally or through a Nasogastric or gastrostomy tube Oral coverage however, does not include the provision of �routine� infant formulae For the general Medicaid population, coverage is limited to when the supplement is the sole source form of nutrition and necessary to treat a medical condition

56. 56 SPECIFIC GUIDELINES FOR ENTERAL NUTRITION SOLE SOURCE: Inability to swallow or absorb any other form of oral nutrition For individuals in the Technology-Assisted, AIDS Waiver or EPSDT programs, coverage is limited to when the supplement is at least the primary source form of nutrition and is medically necessary to treat a medical condition.

57. 57 SPECIFIC GUIDELINES FOR ENTERAL NUTRITION PRIMARY SOURCE: Inability to tolerate nutrients. The recipient may either be unable to swallow any oral nutrition or the oral intake that can be tolerated is inadequate to maintain life

58. 58 SPECIFIC GUIDELINES FOR ENTERAL NUTRITION WIC Program For recipients under the age of five, the DME provider must have documentation from the WIC program regarding the extent of coverage of nutritional supplements available through WIC Medicaid is payor of last resort Medicaid will only reimburse the DME provider for the portion of the recipient�s total caloric order (per DMAS-115 form, section F) that is not covered by WIC

59. 59 ENTERAL NUTRITION Brand name of supplement or category of Enteral nutrition must be documented Provider must supply specific supplement if ordered by physician Prior authorization is not required for nutritional supplements

60. 60 REQUIRED FORMS FOR ENTERAL NUTRITION The CMN/DMAS-352 form is required for all nutritional supplements and supplies regardless of whether or not the recipient is enrolled in a waiver program The CMN must specify either a brand name of the supplement being ordered or the category of Enteral nutrition that must be provided. If a physician orders a specific supplement, the DME provider must supply the brand prescribed.

61. 61 REQUIRED FORMS FOR ENTERAL NUTRITION The CMN must be signed and dated by the physician within 60 days of the begin service date If not signed within 60 days of the begin service date, it will be valid on the date of the physician�s signature If the physician order changes, a new CMN is required

62. 62 REQUIRED FORMS FOR ENTERAL NUTRITION The CMN ordering nutritional supplements is valid for a maximum of six months from the CMN begin service date, regardless of the age of the recipient. A new CMN is required every six months for ongoing nutritional supplement services. The DMAS-115 form (revised 10/99) is required The DMAS-115 must be signed and dated by the assessor within 60 days of the begin service date

63. 63 REQUIRED FORMS FOR ENTERAL NUTRITION If the DMAS-115 is not signed and dated by the assessor within 60 days, the DMAS-115 will not be valid until the date of the assessor�s signature Must be completed by physician, registered nurse or dietician as part of a face-to-face nutritional assessment If the physician order changes, a new DMAS-115 is required.

64. 64 REQUIRED FORMS FOR ENTERAL NUTRITION Maximum validity of the DMAS-115 is six months from the begin service date regardless of the age of the recipient. A new DMAS-115 is required every six months for ongoing nutritional supplement services.

65. 65 ENTERAL NUTRITION BILLING When HCPCS codes B4154 and B4155 are used, a copy of completed DMAS-115 and suppliers manufacturer�s invoice must be attached to the claim. The invoice must document cost per package/can and calories per package/can

66. 66 DMAS-115NUTRITIONAL STATUS EVALUATION FORM The DMAS-115 must be completed as part of the nutritional evaluation The DMAS-115 must be fully completed, which includes the signature and complete date by the assessor.

67. 67 EQUIPMENT REPAIRS The cost to repair rental equipment is considered the DME provider�s responsibility Charges for repair(s) to medically necessary, recipient owned equipment may be billed to DMAS using the proper DMAS HCPCS code. The provider should document in recipient record if the equipment is recipient owned Labor is for repairing the equipment and not administrative service or driving time to/from the recipient�s home

68. 68 EQUIPMENT REPAIRS The provider must accept Medicaid payment as payment in full, and may not bill the recipient for any portion of the repair, including shipping and handling charges

69. 69 DME RENTAL/PURCHASE GUIDELINES RENTAL SHORT-TERM USE CONDITION IS EXPECTED TO CHANGE PURCHASE LONG-TERM USE CONDITION IS NOT EXPECTED TO CHANGE

70. 70 DME RENTAL GUIDELINES DMAS will NOT pay for rental days that DME service is not used by the recipient Rental beyond the allowable limits in the DME Listing requires prior authorization When it is determined that an item was rented when the item should have been purchased, DMAS will only provide reimbursement up to the established purchase price

71. 71 DME RENTAL GUIDELINES There are rental/purchase guidelines in the Manual for specific DME items: Apnea Monitors CPAP TENS Units Augmentative Communication Devices DMAS requires documentation of recipient�s benefit and compliance

72. 72 HOME INFUSION THERAPY See DME and Supplies Manual, Chapter IV Definition: Intravenous (IV) administration of fluids, drugs, chemical agents, or nutritional substances to recipients in the home setting.

73. 73 HOME INFUSION THERAPY The home IV payment methodology is not applicable to: subcutaneous delivery intramuscular delivery clysis delivery site care Enteral/Foley care

74. 74 HOME INFUSION THERAPYCOVERAGE CRITERIA State Plan Medically necessary to treat a recipient�s medical condition; In accordance with accepted medical practice; and Not for the convenience of the recipient or the recipient�s caregiver

75. 75 HOME INFUSION THERAPYCOVERAGE CRITERIA Recipient Must reside in either a private home or a domiciliary care facility, such as an adult care residence Must be under the care of a physician who prescribes the home infusion therapy and monitors the progress of the therapy

76. 76 HOME INFUSION THERAPYCOVERAGE CRITERIA Must have body sites available for IV catheter or needle placement or have central venous access Must be capable of self-administering or have a caregiver that can be adequately trained, is capable, and willing to administer/monitor home infusion therapy safely and efficiently

77. 77 HOME INFUSION THERAPYCOVERAGE CRITERIA Provider Must have a valid DME Medicaid Provider number to participate in and to bill for the DME Service Day Rate component of Home Infusion Therapy. Providers must adhere to the provider participation requirements.

78. 78 Incompatible Drug TherapyZ7778 Local code Z7778 ended 12/31/03 It included rental of second infusion pump and purchase of administration tubing Z7778 not replaced by a national code In place of this code use the individual codes for the pump rental and administration tubing

79. 79 DME FOR WAIVER RECIPIENTS Recipients enrolled in a Medicaid Waiver may receive any medically necessary DME available to the general Medicaid population A fully completed CMN/DMAS-352 is required Recipients in the Tech or AIDS Waivers may receive Enteral nutrition that does not contain a legend drug when it is the primary source of nutrition

80. 80 TECHNOLOGY ASSISTED WAIVER DME Utilize same criteria and documentation in Durable Medical Equipment and Supplies Manual, including Appendix B Preauthorization is requested via fax from the Waivered Services Unit at DMAS 804-371-4986 For questions regarding preauthorization for Tech Waiver recipients contact 804-786-1465 and ask to speak with the Tech Waiver case manager for the recipient

81. 81 TECHNOLOGY ASSISTED WAIVER DME Documentation to submit for preauthorization DMAS 351 � Preauthorization Request Form DMAS 352 � Certificate of Medical Necessity Supporting Documentation, letter, evaluation as appropriate Cost for Individual Consideration HCPCS codes Usual and Customary Pricing for National HCPCS codes listed in Appendix B with no pricing

82. 82 ORTHOTICS Orthotic device services include devices that support or align extremities to prevent or correct deformities, or improve functioning, and services necessary to design the device, including measuring, fitting and instructing the recipient in its use

83. 83 ORTHOTICS Orthotics, including braces, splints, and supports, are not covered for the general adult Medicaid population under the DME program, with the exception with the Intensive Rehabilitation program. All medically necessary orthotics are covered for children under the age of 21 years through the EPSDT program

84. 84 ORTHOTICS To learn more about orthotics coverage, or documentations requirements contact: - DMAS Payment Processing Unit at 804-225-3536 Preauthorizations are accepted via fax at 804-225-2603 or 1-866-248-8796

85. 85 RECONSIDERATIONS AND APPEALS FOR SERVICES AUTHORIZED BY DMAS Reconsiderations based upon preauthorizations requested from DMAS must be mailed within 30 days of the denial to the unit performing the preauthorization function Appeals of adverse reconsiderations may be mailed within in 30 days of the denial to: Director, Appeals Division 600 East Broad Street, Suite 1300 Richmond, VA 23219

86. 86 Nursing Home Residents Requests for coverage of resident specific, customized items for nursing home residents are made through the DMAS Map-122 process by the nursing home DME providers can assist in this process by providing the nursing home with an invoice reflecting updated national codes documentation of cost to the DME provider for each code

87. 87 UTILIZATION REVIEW State Plan (VAC - Virginia Administrative Code) Requires Periodic Utilization Review Of All Medicaid Services

88. 88 UTILIZATION REVIEW DMAS will be conducting on-site or desk utilization review activities throughout the state!

89. 89 UR - PROVIDER RESPONSIBILITY Verify recipient�s Medicaid eligibility Obtain PA when required Deliver only item(s) ordered by the physician on the CMN/DMAS-352 Deliver only the quantities ordered by the physician on the CMN/DMAS-352 Deliver only the item(s) for the periods of service covered on the physician�s order

90. 90 UR - PROVIDER RESPONSIBILITY Maintain physician�s order and supporting documentation Document and justify the description of services Document all equipment and supplies provided to a recipient in accordance with physician�s order

91. 91 UR - PROVIDER RESPONSIBILITY Documentation of service provision. The delivery ticket must document: the recipient�s name the date of delivery what was delivered � include accessories to main item ordered on CMN quantity delivered

92. 92 UTILIZATION REVIEWDMAS RESPONSIBILITY DMAS conducts professional reviews with respect to the: Care being provided by the DME provider Adequacy of the services Necessity of continued service to the recipient Feasibility of meeting recipient�s health needs Verification of existence of all Medicaid required documentation

93. 93 UTILIZATION REVIEWDMAS RESPONSIBILITY DMAS will deny or retract payment if: No valid CMN/DMAS-352 Documentation does not verify the item was provided Lack of medical documentation to justify the DME The item does not meet DMAS criteria Utilization Review Summary letter, including retraction findings, when applicable.

94. 94 TOP REASONS FOR RETRACTIONS CMN: Missing / Invalid / Incomplete / Expired / Outdated or Altered Insufficient medical documentation Service provided in excess of physician�s order/CMN Medical necessity not justified Service delivery not documented

95. 95 TOP REASONS FOR RETRACTIONS Item not covered or does not meet DMAS coverage criteria Items rented vs.. purchased Frequency does not justify quantity provided Providing chux and diapers in the same month without a separate medical need

96. 96 TOP REASONS FOR RETRACTIONS Supplying two mobility devices on the same date without documentation to support each device Services included in other program reimbursement (standard parts, home health nursing, etc.) Billing for supplies used outside the home (M.D. office or home health clinic)

97. 97 TOP REASONS FOR RETRACTIONS Enteral Nutrition Policy: Failure to obtain a new CMN and DMAS-115 every six months Failure to complete the DMAS-115 form Using the outdated DMAS-115 form Enteral Nutrition Policy: Misunderstanding of the proper calculation of units for billing Not following policy of �sole source� of nutrition for adults

98. 98 UTILIZATION REVIEWPROVIDER APPEAL PROCESS Must submit reconsideration request within 30 days to DMAS. Request must include supporting documentation May appeal reconsideration denial within 30 Days

99. 99 Important Information The Facility and Home Based Services Unit phone number is 804-225-4222. Our Fax number is 804-371-4986. Our address is DMAS-F&HBSU 600 East Broad Street, Suite 1300 Richmond, Virginia 23219 Please feel free to visit our web site at: www.dmas.virginia.gov

100. 100 Thank You! Paula Drever, MS 804-225-4222

101. 101 DME Preauthorization

102. 102 Purpose of Preauthorization �The purpose of preauthorization is to validate that the service or item being requested is medically necessary and meets DMAS criteria for reimbursement.� DME and Supplies Manual, Ch. IV, pg. 5

103. 103 What requires preauthorization? Any item that is identified by a �Y� in the �Authorization� column of the Appendix B. Any item that is identified by a �N� in the �Authorization� column of the Appendix B and has exceeded the time frame in the �Limits� column. Any custom equipment for a child residing in a nursing facility. Any item that uses the HCPCS code E1399.

104. 104 What documentation is required? Minimum Documentation required: Physician signed and dated Certificate of Medical Necessity, DMAS 352(CMN) Completed Preauthorization Request form, DMAS 351 (fax and mail requests) Signed and dated IV Therapy Implementation form, DMAS 354 (IV therapy requests only) Signed and dated Maternity Risk Screen, DMAS 16 (high risk pregnancy only) Additional Documentation: Wheelchair evaluation Sleep/titration study Augmentative communication device evaluation. Letter of Medical Necessity Documentation of retail and/or actual provider cost of item requested All supporting documentation must be signed and dated by the physician.

105. 105 Medical NecessityMedically necessary DME and supplies shall be: Ordered by the physician on the CMN/DMAS-352 Ordered by the MEDALLION primary care physician (PCP) or referred for the service by the MEDALLION PCP, if the recipient is enrolled in MEDALLION A reasonable and medically necessary part of the recipient�s treatment plan Suitable for use in the recipients home environment Consistent with the recipient�s diagnosis and medical condition, particularly the functional limitations and symptoms exhibited by the recipient. Furnished at a safe, effective, and cost effective level. Not furnished for the safety or restraint of the recipient, or solely for the convenience of the family, attending physician, or other practitioner or supplier.

106. 106 CMN - Requirements DME and supplies must be ordered by a physician on the CMN/DMAS-352 Alternative versions of the CMN/DMAS-352 are not accepted The CMN/DMAS-352 may be completed by the DME provider, the physician or a health care professional. DME and supplies must be medically necessary to treat a health care condition All DME and supplies MUST be listed on the CMN The physician must sign and date the CMN within 60 days of the CMN begin service date DMAS will not reimburse the DME provider for services provided prior to the date of the physician�s signature when the signature is not obtained within 60 days of the begin service date The CMN cannot be changed, altered or amended after the attending physician has signed and dated the CMN

107. 107 CMN � InstructionsSection I Recipient and Provider Data: Must contain the 12 digit ID number for the recipient Provider contact person and telephone number

108. 108 CMN - InstructionsSection II Recipient Information This section contains 8 yes/no questions that should be answered relevant to the patient�s condition. If yes and related to the ordered item, more clinical information should be presented. There are also two questions that follow the 8 yes/no questions and should be answered on the CMN or in the supporting documentation: Is the item suitable and usable in the home? Does the patient/caregiver demonstrate ability and willingness to use the equipment?

109. 109 CMN- InstructionsSection II (continued) ICD-9 code is optional Clinical diagnosis-narrative MUST be identified Diagnosis MUST be related to the item requested Check appropriate line for date of onset The description/additional information box next to the 8 yes/no questions can be used for the addition of needed clinical information

110. 110 CMN � InstructionsSection III All sections should be completed Begin service date � month, day and year Item ordered/description � MUST be a narrative description DME provider may identify by HCPCS code (Use HCPCS code identified in the Appendix B) Do not use �PRN� for frequency in Section III Length of time needed � identify how long the recipient will need the DME service. This should be done for each item and should not be confused with CMN validity time Quantity/frequency of use-physician�s order MUST be identified Describe recipient�s unique needs or condition

111. 111 CMN � InstructionsSection III Quantity ordered per month Must be based on the individual assessment of each recipient and each DME service/item Expendable supplies: designate supplies needed for one month, allowable and overages If items require greater than one month, note the time frame in the �Length of Time Needed� column

112. 112 CMN � InstructionsSection IV Physician Certification Must be signed and dated by the physician Physician prescription will not be accepted If orders continue on second page, physician MUST sign and date both pages Print physician�s name on form Physician provider number is optional

113. 113 Preauthorization Request form � DMAS 351 and 361 There are 2 versions of the 351 form. The original 351 (5/94) and the 351R (6/03). Both forms are acceptable. The 361 form should be used when submitting pend information or requesting reconsideration. All fields should be completed on both forms. See Handouts for examples of required preauthorization forms. Forms can be found at www.dmas.virginia.gov.

114. 114 The medical need for the DME The diagnosis related to the DME request The recipient�s functional limitation and its relationship to the requested DME How the DME service will treat the recipient�s medical condition. The quantity needed and why that amount is needed The frequency of use The estimated length of use of the equipment Conjunctive treatment related to the DME/supplies Alternatives explored/tried and describe success/failure General Documentation RequirementsThere must be a fully completed CMN and the documentation must identify:

115. 115 General Documentation Requirements Must identify: How the needs were previously met � identify what changes have occurred which necessitate the DME How the service will be used (and is required) within the recipient�s home environment, the recipient/caregiver ability, willingness, and motivation to use the equipment Assessments/evaluations from other Health Care Professionals: -Nurses, Rehabilitative therapists, Rehabilitation engineers, DME professionals. All supporting documentation must be signed and dated by the physician Supporting documentation does not replace the requirement of a fully completed CMN

116. 116 Documentation Requirements and Coverage Criteria Hospital Beds Patient Lifts Wheelchairs Wound Care Supplies Augmentative Communication Devices Assistive Technology Equipment Blood Glucose Monitors Disposable Incontinent Supplies Disposable Supplies for Infection Control Adult Pull Up Style Briefs Enteral Nutrition Home Infusion Therapy Equipment Repairs Rehabilitative Equipment Respiratory Equipment Therapeutic Beds and Mattresses TENS Units DME and Supplies Manual, Chapter IV, pages 13-59

117. 117 Pricing informationMedicaid Memo: Special, March 19, 2004, pg 2 DME ITEM 1. DME items that have a national code and a DMERC rate 2. DME items that have a July 1, 1996 rate, but do not have a national code 3. DME items that have a national code, but do not have a DMERC or a July 1, 1996 rate 4. DME items that do not have a national code, and do not have a July 1, 1996 rate RATE 1. Rate will be the DMERC rate. 2. Bill the E1399 code (miscellaneous). The rate will continue to be the July 1, 1996 rate. 3. Rate will be the usual and customary charge to the general public. 4. Bill the E1399 code (miscellaneous). Rate will be the manufacturer's cost, plus 30%.

118. 118 DME Rental/Purchase Guidelines Rental Short-term use Condition is expected to change Purchase Long-term use Condition is not expected to change Relative to the length of time the DME service is ordered on the CMN.

119. 119 DME Rental Guidelines DMAS will not pay for rental days that DME service\item is not used by the recipient Rental beyond the allowable limits in the DME listing requires preauthorization When it is determined that an item was rented when the item should have been purchased, DMAS will only provide reimbursement up to the established purchase price Rental/purchase guidelines for the following DME items can be found in the DME Manual. CPAP/BiPAP Apnea monitors TENS Units Augmentative Communication Devices These items require documentation of recipient benefit and compliance for continued rental or conversion from rental to purchase.

120. 120 Helpful Tips Read the Manual Complete 351/351R thoroughly and accurately Complete DMAS 352 (CMN) thoroughly Send the appropriate evaluation/supporting documentation with the request The dates of supporting documentation must coincide with the dates of service on the CMN Do not alter the CMN once the physician had signed and dated Providers may call the Inquiry line at WVMI to check the status of a request When making a phone request, write down the pend information we are requesting If you receive a pend letter stating this is the second request, call WVMI to have your pend explained

121. 121 Decision Types The analyst can make several decision based on the information received, these could include: Approve Pend for more information Reject Deny or Partially approve For any dates of service/units denied the provider then has the right to reconsideration with the supervisor. If the reconsideration is upheld the provider then has appeal rights.

122. 122 Top Pend and Reject Reasons Rejects Duplicate request or overlapping dates of service with a previous authorization Missing information on 351 R and CMN. (Dates of service, number of units, provider/ recipient information; CMN sections II and III) Incorrect HCPCS codes or no codes Code submitted does not require authorization Pends No clinical information submitted with request Missing pricing information Clinical information was submitted, however additional medical justification was needed Is the equipment patient owned Is the item useable/suitable in the home Supporting documentation is not signed and dated by the physician

123. 123 Reconsideration Denials � The provider may request reconsideration within 30 days of the date of the denial by writing to: WVMI Supervisor, Outpatient Review Services 6802 Paragon Place, Suite 410 Richmond, VA 23230 -or by faxing request to Outpatient Supervisor at 1-888-243-2770

124. 124 Appeals If reconsideration is upheld a written request for appeal may be submitted to: Director, Division of Appeals Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, Virginia 23219

125. 125 Request Overview 83% of all DME requests are fax reviews 17% of all DME requests are phone reviews 89% of all calls are answered; messages are returned within one business day The average turn around time on faxes is 4-5 days

126. 126 Contact InformationWVMI - Phone � (800) 299-9864 or (804) 648-3159 Hours of operation: 8-5 Fax � (888) 243-2770 or (804) 648-6880 24 hours per day Questions about a specific request Call WVMI Outpatient Inquiry Line 804-648-315 or 800-299-9864, press Option 5 and then Option 2 - Website � www.qiva.org

127. 127 Durable Medical EquipmentEligibility VerificationCMS-1500 Billing www.dmas.virginia.gov

128. 128 Objectives How to correctly utilize the various Medicaid options to verify eligibility How to optimize Medicaid resources Understanding timely filing guidelines How to submit of DME claims, adjustments and voids

129. 129 As A Participating ProviderYou Must- Determine the patient�s identity. Verify the patient�s age. Verify the patient�s eligibility. Accept, as payment in full, the amount paid by Virginia Medicaid. Bill any and all other third-party carriers.

130. The most visible change will be the implementation of the new plastic Medicaid card. Here is an example of the format. The most visible change will be the implementation of the new plastic Medicaid card. Here is an example of the format.

131. 131 Medicaid Verification Options MediCall ARS- Web-Based Medicaid Eligibility

132. 132 MediCall 800-884-9730 800-772-9996 804-965-9732 804-965-9733

133. 133 MediCall Available 24 hours a day, 7 days a week Medicaid Eligibility Verification Claims Status Prior Authorization Information Primary Payer Information Medallion Participation Managed Care Organization Assignment

134. 134 Automated Response SystemARS Web-based eligibility verification option Free of Charge. Information received in �real time�. Secure Fully HIPAA compliant

135. 135 Automated Response SystemARS Medicaid client eligibility/benefit verification Service limit information Claim status Prior authorization Provider check log

136. 136 Automated Response SystemARS Registration virginia.fhsc.com Questions concerning registration process Web Support Helpline 800-241-8726

137. 137 ARS User Guide Available Located on the DMAS web-site under Provider Services section General information on ARS eligibility verification Instructions on the using the system �FAQ�(frequently asked questions) section

138. 138 Provider Call Center Claims, covered services, billing inquiries: 800-552-8627 804-786-6273 8:30am � 4:30pm (Monday-Friday) 11:00am � 4:30pm (Wednesday)

139. 139 Billing Inquiries

140. 140 Provider Enrollment New provider numbers or change of address: First Health � PEU P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax

141. 141 Requests for DMAS Forms and Manuals: DMAS Order DeskCOMMONWEALTH MARTIN1700 Venable StreetRichmond, Virginia 23222

142. 142 Electronic Billing Electronic Claims Coordinator Mailing Address First Health Services CorporationVirginia OperationsElectronic Claims Coordinator4300 Cox RoadGlen Allen, VA 23060 E-mail: edivmap@fhsc.com Phone: (800) 924-6741 Fax: (804) 273-6797

143. 143 DMAS Website Current, most up-to-date information on Virginia Medicaid programs Provider memos available for review Access to Medicaid manuals Numeric Insurance Code List Primary Carrier Coverage Code List

144. 144 DMAS Website Financial Reason Code Description List Top 50 Error Reason Denial Codes and Resolutions Medicaid Forms 2004 Medicaid Client Handbook

145. Billing on the CMS-1500

146. 146 MAIL CMS-1500 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES PRACTITIONER P. O. Box 27444 Richmond, Virginia 23261

147. 147 TIMELY FILING ALL CLAIMS MUST BE SUBMITTED AND PROCESSED WITHIN ONE YEAR FROM THE DATE OF SERVICE EXCEPTIONS Retroactive Eligibility Delayed Eligibility Denied Claims NO EXCEPTIONS Accident Cases Other Primary Insurance

148. 148 TIMELY FILING Submit claims with documentation attached explaining the reason for delayed submission You must have the word �Attachment� in Locator 10d and use modifier �22� in Locator 24D

168. 168 Special Billing Instructions

169. 169 Billing Allowables and Overages Effective with claims received after 4/21/05: Allowables and overages can be billed on the same claim form Allowable and overages are to be billed on one claim line The preauthorization number must be included on the claim

170. 170 Allowables and OveragesExamples Ex: Claim is for 50 units for 06/01-06/30/05 for procedure code A1234. DMAS allows 30 per month without PA for code A1234. The PA is authorized for 10 units for 06/01-06/30/05. The claims would pay the 30 units (these are the service allowed unit) and then add the 10 from PA file and cut back for another 10 units.

171. 171 Allowables and OveragesExamples Ex: Claim is for 50 units for 06/01-06/30/05 for procedure code A1234. DMAS allows 30 per month without PA for code A1234. The PA is authorized for 40 units for 06/01-06/30/05. The claims would pay the 30 units (these are the service allowed unit) and then add 20 from PA file and total payment would be for 50 units.

172. 172 Allowables and OveragesExamples Ex: Claim is for 50 units for 06/01-06/30/05 for procedure code A1234. DMAS allows 30 per month without PA for code A1234. The PA is authorized for 20 units for 07/01-07/30/05. The claims would pay the 30 units (these are the service allowed unit) only and cut back for 20 units. Note, the PA is for July, therefore no PA units.

173. 173 Locator 29-Amount Paid Field As of May 1, 2005 Medicaid with read Locator 29 of the CMS 1500 for �patient pay� information on clients enrolled in waiver services Waivers affected: MR (Mental Retardation) IFDDS (Individual and Family Developmental Disabilities) EDCD (Elderly and Disabled w/Consumer Direction)

174. 174 Locator 29-Amount Paid Field DMAS will now read this field and deduct any amount listed from the amount considered for reimbursed This pertains to clients in any of the listed waiver services This pertains to all provider types

175. 175 Multiple E1399 Billing Providers will receive prior authorization at the line level for each E1399 code reference � MC lines PA will create cumulative �roll up� line of all miscellaneous codes � AC line Provider will �roll up� all misc. codes into one claim for all authorized units and charges (one line item on the 1500)

177. REMITTANCE VOUCHERSections of the Voucher APPROVED for payment. PENDING for review of claims. DENIED no payment allowed. DEBIT (+) Adjusted claims creating a positive balance. CREDIT (-) Adjusted/Voided claims creating a negative balance.

178. REMITTANCE VOUCHERSections of the Voucher FINANCIAL TRANSACTION EOB DESCRIPTION ADJUSTMENT DESCRIPTION/REMARKS- STATUS DESCRIPTION REMITTANCE SUMMARY- PROGRAM TOTALS

180. 180 THANK YOU Department of Medical Assistance Services www.dmas.virginia.gov