Paula Drever

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DME TRAINING July - August 2005

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

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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

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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

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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

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Medicaid Resources

• Websites
• Emails
• Important phone/fax numbers

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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

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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
  recipients treatment plan

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MEDICAL NECESSITY

• Consistent with the recipients 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

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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 recipients home
  environment

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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

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CMN - REQUIREMENTS

• The CMN/DMAS-352 may be completed by
• DME Provider
• Physician
• Health Care Professional

but it must be signed and dated by the physician
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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

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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
  physicians signature when the signature is not
  obtained within 60 days of the begin service date
  (section III of the CMN)

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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

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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
  recipients condition, for the ordered DME or
  supplies, the DME provider must obtain a new
  CMN/DMAS-352

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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

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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
  recipients medical need for the DME or supplies
  ends

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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 recipients age

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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

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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)

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CMN MAINTENANCE

• Fully completed CMN (and supporting
  documentation) must be kept in the recipients
  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

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COMPLETING THE CMN

• DMAS 352 Revised 8/95

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CMN - SECTION I (Recipient and Provider Data)

• Complete all information in section I
• Recipient Data
• ID is the 12 digit Enrollee ID
• A new CMN is not required if this number changes

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CMN SECTION II - RECIPIENT INFORMATION
Completing ALL information in Section II assists
in describing the medical necessity and meeting
documentation requirements

• If questions on left are yes, describe how
  limitation and how item treats the medical
  condition on the right. Refer to documentation
  guidelines in Chapter IV.

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CMN SECTION II (Contd) - DIAGNOSIS

• 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

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CMN - SECTION III

• All sections MUST be completed
• This is the physicians order for treatment and
  requests will be pended, and/or retractions will
  be made upon post payment review, if this section
  is incomplete

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CMN - SECTION III (Contd)

• 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

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CMN - SECTION III (Contd)

• 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

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CMN - SECTION III (Contd)

• Item ordered description
• Must include narrative description
• Should clearly identify each item ordered

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CMN - SECTION III (Contd)

• Length of time needed
• Identify how long the recipient will need the DME
  service
• Do not confuse with the CMN validity time

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CMN - SECTION III (Contd)

• Quantity Ordered x 1 Month
• Should be based upon the quantity required to
  carry out the physicians 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.

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CMN - SECTION III (Contd)

• 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

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CMN - SECTION IV Physician Certification

• Must be signed and dated by the physician
• Physician prescription will not be accepted
• Ordering physicians name, printed on form
• Physician provider number is optional
• Physician telephone number (include area code)

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CMN Second page

• If orders or additional information continue on
  the back page the physician MUST sign and date
  this page also!

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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.

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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

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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
  manufacturers cost (to the provider) plus 30.
• Documentation showing cost may be in the form of
  an invoice or estimate

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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

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Documentation Requirementsfor All DME

• Must Identify
• The recipients functional limitation and its
  relationship to the requested DME
• How the DME service will treat the recipients
  medical condition
• How the needs were previously met-identify what
  changes have occurred which necessitate the DME

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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

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Documentation Requirementsfor All DME

• Must identify
• How the service will be used (and is required)
  within the recipients home environment, and
• The recipient or caregivers ability,
  willingness, and motivation to use the equipment
• Alternatives explored/tried and describe
  success/failure

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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

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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

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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

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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

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DOCUMENTATION REQUIREMENTS AND COVERAGE CRITERIA

• Enteral Nutrition
• Home Infusion Therapy
• Rehabilitative Equipment
• Respiratory Equipment

• Therapeutic Beds and Mattresses
• TENS Units
• Orthotics

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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

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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

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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

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SPECIFIC GUIDELINES FOR WHEELCHAIRS

• Describe recipients 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 recipients home environment

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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

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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

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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.

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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

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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 recipients total caloric
  order (per DMAS-115 form, section F) that is not
  covered by WIC

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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

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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.

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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
  physicians signature
• If the physician order changes, a new CMN is
  required

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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

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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 assessors
  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.

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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.

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ENTERAL NUTRITION BILLING

• When HCPCS codes B4154 and B4155 are used, a copy
  of completed DMAS-115 and suppliers
  manufacturers invoice must be attached to the
  claim. The invoice must document cost per
  package/can and calories per package/can

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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.

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EQUIPMENT REPAIRS

• The cost to repair rental equipment is considered
  the DME providers 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 recipients home

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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

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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
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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

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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 recipients
  benefit and compliance

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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.

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HOME INFUSION THERAPY

• The home IV payment methodology is not applicable
  to
• subcutaneous delivery
• intramuscular delivery
• clysis delivery
• site care
• Enteral/Foley care

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HOME INFUSION THERAPYCOVERAGE CRITERIA

• State Plan
• Medically necessary to treat a recipients
  medical condition
• In accordance with accepted medical practice and
• Not for the convenience of the recipient or the
  recipients caregiver

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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UTILIZATION REVIEW

• State Plan (VAC - Virginia Administrative Code)
  Requires Periodic Utilization Review Of All
  Medicaid Services

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UTILIZATION REVIEW

• DMAS will be conducting on-site or desk
  utilization review activities throughout the
  state!

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UR - PROVIDER RESPONSIBILITY

• Verify recipients 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 physicians order

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UR - PROVIDER RESPONSIBILITY

• Maintain physicians order and supporting
  documentation
• Document and justify the description of services
• Document all equipment and supplies provided to a
  recipient in accordance with physicians order

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UR - PROVIDER RESPONSIBILITY

• Documentation of service provision. The delivery
  ticket must document
• the recipients name
• the date of delivery
• what was delivered include accessories to main
  item ordered on CMN
• quantity delivered

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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 recipients health needs
• Verification of existence of all Medicaid
  required documentation

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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.

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TOP REASONS FOR RETRACTIONS

• CMN Missing / Invalid / Incomplete / Expired /
  Outdated or Altered
• Insufficient medical documentation
• Service provided in excess of physicians
  order/CMN
• Medical necessity not justified
• Service delivery not documented

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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

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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)

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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

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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

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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-FHBSU
• 600 East Broad Street, Suite 1300
• Richmond, Virginia 23219
• Please feel free to visit our web site at
  www.dmas.virginia.gov

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Thank You!

• Paula Drever, MS
• 804-225-4222

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DME Preauthorization

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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

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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.

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What documentation is required?

• 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.

• 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)

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Medical NecessityMedically necessary DME and
supplies shall be

• Consistent with the recipients 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.

• 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
  recipients treatment plan
• Suitable for use in the recipients home
  environment

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
  physicians 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
CMN InstructionsSection I

• Recipient and Provider Data
• Must contain the 12 digit ID number for the
  recipient
• Provider contact person and telephone number

108
CMN - InstructionsSection II

• Recipient Information
• This section contains 8 yes/no questions
  that should be answered relevant to the patients
  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
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
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-physicians order MUST
  be identified
• Describe recipients unique needs or condition

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
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 physicians name on form
• Physician provider number is optional

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
General Documentation RequirementsThere must be
a fully completed CMN and the documentation 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 DME/supplies
• Alternatives explored/tried and describe
  success/failure

• The medical need for the DME
• The diagnosis related to the DME request
• The recipients functional limitation and its
  relationship to the requested DME
• How the DME service will treat the recipients
  medical condition.

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 recipients 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
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
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
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
DME Rental Guidelines

• 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.

• 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

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
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
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
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
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
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
Contact InformationWVMI

• - Phone [phone] or [phone]
• Hours of operation 8-5
• Fax [phone] or [phone]
• 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
Durable Medical EquipmentEligibility
VerificationCMS-1500 Billing

• www.dmas.virginia.gov

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
As A Participating ProviderYou Must-

• Determine the patients identity.
• Verify the patients age.
• Verify the patients eligibility.
• Accept, as payment in full, the amount paid by
  Virginia Medicaid.
• Bill any and all other third-party carriers.

130
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
002286
9 9 9 9 9 9 9 9 9 9 9 9
V I RG I N I A J. R E C I P I E N T
DOB 05/09/1964 F
CARD 00001
131
Medicaid Verification Options

• MediCall
• ARS- Web-Based Medicaid Eligibility

132
MediCall

• 800-884-9730
• 800-772-9996
• 804-965-9732
• 804-965-9733

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
Automated Response SystemARS

• Web-based eligibility verification option
• Free of Charge.
• Information received in real time.
• Secure
• Fully HIPAA compliant

135
Automated Response SystemARS

• Medicaid client eligibility/benefit verification
• Service limit information
• Claim status
• Prior authorization
• Provider check log

136
Automated Response SystemARS

• Registration
• virginia.fhsc.com
• Questions concerning registration process
• Web Support Helpline 800-241-8726

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
Provider Call Center

• Claims, covered services, billing inquiries
• 800-552-8627
• 804-786-6273
• 830am 430pm (Monday-Friday)
• 1100am 430pm (Wednesday)

139
Billing Inquiries
Customer Service Department of Medical
Assistance Services 600 East Broad Street, Suite
1300 Richmond, VA 23219
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
Requests for DMAS Forms and Manuals

• DMAS Order DeskCOMMONWEALTH MARTIN1700
  Venable StreetRichmond, Virginia 23222

Phone [phone] Emaildmas_at_cms-mpc.com
142
Electronic Billing

• Electronic Claims Coordinator
• Mailing Address
• First Health Services CorporationVirginia
  OperationsElectronic Claims Coordinator4300 Cox
  RoadGlen Allen, VA 23060
• E-mail edivmap_at_fhsc.com
• Phone [phone]
• Fax [phone]

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
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
MAIL CMS-1500 FORMS TO

• DEPARTMENT OF MEDICAL ASSISTANCE
• SERVICES
• PRACTITIONER
• P. O. Box 27444
• Richmond, Virginia 23261

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
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

149
Block 1 Check Medicaid
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
2. PATIENT'S NAME (Last Name, First Name, Middle
Initial)
CHECK MEDICAID BLOCK ONLY
48
150
Block 1a Recipient ID Number
1a. INSURED'S I.D. NUMBER (FOR PROGRAM
IN ITEM 1)
123456789 01 4
(Be sure to include all 12 digits)
49
151
Block 2 Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle
Initial)
Smith, Sam
5. PATIENT'S ADDRESS (No., Street)
50
152
Block 10 Accident-Related
10. IS PATIENT'S CONDITION RELATED TO
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
YES
NO
PLACE (State)
b. AUTO ACCIDENT?
YES
NO
c. OTHER ACCIDENT?
NO
YES
You MUST check YES or NO for a, b c
51
153
Block 10d
10d. RESERVED FOR LOCAL USE
ATTACHMENT
You MUST use the word "ATTACHMENT"
if you attach anything to the HCFA form.
52
154
Blocks 17 and 17a- Conditional
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17- Name of the Recipients PCP
(primary care physician) 17a- PCPs 9-digit
Medicaid provider ID
17a. ID NUMBER OF REFERRING PHYSICIAN
(Medicaid 9-digit provider ID)
53
155
Block 21 Diagnosis Codes
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3441
1.
3.
2963
2.
4.
May enter up to 4 codes
Omit decimals
55
156
Block 23 Prior Authorization Number - Conditional
23. PRIOR AUTHORIZATION NUMBER
If service requires prior authorization, enter
the eleven digit PA number assigned by WVMI.
56
157
Block 24A Dates of Service
24. A
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
05
05
03
01
03
01
1
03
05
01
31
05
03
2
Both FROM and TO dates
must be completed
Dates must be within same calendar month
57
158
Block 24B Place of Service Block 24C Type of
Service
B
C
Type
Place
of
of
11-Office location 12- Patients home
Service
Service
11
1
1- Medical Care
Medicaid accepts the same Place of Service and
Type of Service as Medicare.
58
159
Block 24D Procedure Codes
D
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
A4450
22
E0180
RR
Medicaid now utilizes the RR modifier to indicate
a rental item
59
160
Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
34431
1.
3.
2963
2.
4.
E
DIAGNOSIS
CODE
1
Enter the entry identifier of the ICD-9-CM
diagnosis code listed in Locator 21. To identify
more than one diagnosis code, separate the
indicators with a comma.
1,2
60
161
Block 24 F Charges
F
CHARGES
Enter the usual
and customary charges
61
162
Block 24G Days or Units
G
DAYS
OR
Enter the number of times or hours the procedure,
service, or item was provided during the service
period.
UNITS
1
31
62
163
24J COB Other Insurance 24K Other Insurance
Paid
J
K
RESERVED FOR
LOCAL USE
COB
Attach denial from other carrier or documentation
63
164
Block 26 Patients Account Number (Optional)
26. PATIENT ACCOUNT NUMBER
12345678918765432
64
165
Block 31 Signature Date
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
SIGNED
DATE
If there is a signature waiver
on file, you may stamp, print,
or computer-generate the signature.
65
166
Block 33 Provider ID and Address
33. PHYSICIAN'S, SUPPLIER'S BILLING NAME,
ADDRESS, ZIP CODE
PHONE
123456789
PIN
GRP
Be sure to put the MEDICAID
9-digit ID number!
66
167
Block 22 Adjustments and Voids
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
1032
xxxxxxxxxxxxxxxx
From original
Adjustment or
remittance
Void
Resubmission Code
Chap. V, Medicaid Physicians Manual has code
list.
67
168
Special Billing Instructions
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
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
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
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
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
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
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)

176
Comparison Actual Amounts Provided and Medicaid
Billing for E1399 Roll Up Ex.Wheelchair parts
Items Supplies by Provider and Related
Dollars Item Dates of Service Units
Amount Foam filled inserts 01/15/05-05/15/05 2 54
4.45 Tilt/Recline Control 01/15/05-05-15/05 1 237
0.55 Cushion 01/15/05-05-15-05 1 374.4 Grand
Total Provided 4 3289.4 Rolled-Up
Line Roll Up line Dates of Service
Units Total Rolled-Up Amount All
E1399s 01/15/05-05/15/05 4 3289.4 Amounts Billed
Using DMAS E1399 Roll Up E1399 4/15/2005 4 82
2.35 Delivery date used in Example
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

179
Before you FLY Please complete and turn in your
evaluation form
180
THANK YOU

• Department of Medical Assistance Services
• www.dmas.virginia.gov