Provider Notice issued 05/07/13

 Prior Approval Required for All Wheelchair and Power-Operated Vehicle (POV) Repairs Effective June 1, 2013

As mandated by Public Act 097-0689 (pdf), referred to as the Save Medicaid Access and Resources Together (SMART) Act, HFS is enforcing the following change to the durable medical equipment and supplies program effective June 1, 2013.

Prior Approval for All Manual and Power Wheelchair and Power-Operated Vehicle (POV) Repairs

Providers must submit an HFS 1409 Prior Approval Request form (pdf) for any repair to a manual or power wheelchair or POV that is patient-owned. HFS will not require that a practitioner's order be included with the Prior Approval request for the repair. Until the department completes all of the necessary system changes for processing of the approval requests, providers must identify on the HFS 1409 the code and the description of the item being repaired and a "Purch/Rent" code of "P". Code K0108 can be used for uncoded items or as a bundled billing code on the HFS 1409, Item #16, for multiple items.

Requests for prior approval of a repair must include the brand name, model and serial number of the wheelchair, purchase date if known and an itemized breakdown of the repairs being done. The department will maintain only one chair per patient. Providers must also include the manufacturer's product and pricing information. If the item is covered under warranty, the repair is the responsibility of the manufacturer and the department should not be billed. For items no longer covered under warranty, providers must state the warranty expiration date on the prior approval form.

Providers should not request payment separately for nuts, bolts, and screws that are included in the allowance of the item being repaired or replaced. The department will not cover a repair when the repair cost (per incident) exceeds 75% of the Department's purchase price. Reimbursement for repairs will be based upon the current methodologies used to determine reimbursement for modifications and for new prior approval requests for manual and power wheelchairs and POV.

The department is committed to handling these repair prior approval requests as expeditiously as possible. Post approval requests may be considered based on the conditions noted in Topic M-211.6 of the current Handbook for Providers of Durable Medical Equipment and Supplies. To be eligible for post approval consideration, all the normal requirements for prior approval of the item must be met and the post approval requests must be received by the Department no later than 90 days from the date services or items are provided or within the time frames identified in Topic M-211.6.

The department notifies providers of an approval via Form HFS 3076A, Prior Approval Notification Letter. Providers must ensure the following steps are taken when submitting a claim for the approved repair.

• For the paper HFS 2210, Medical Equipment/Supplies Invoice, providers must report the prior approval number in the Prior Approval Number field for each service section completed. Providers must enter the last eight digits of the prior approval number, since this field will only accommodate eight digits. The department's system will add the first two digits when editing the field. The paper claim form HFS 2210 Medical Equipment / Medical Supplies (OCR) (pdf) must also identify "Purch/Rent" code "1".

• For the electronic 837P, in accordance with the 837P Implementation Guide, the prior approval number must be entered at the claim level reported in Loop 2300, REF02, Prior Authorization or Referral Number. Providers must enter all 10 digits of the Prior Approval number on electronic claims. When completing the service line level in Loop 2400, if the prior approval number for the service line is different than the number reported in Loop 2300 at the claim level, providers must enter the appropriate prior approval number at the service line level. The electronic claim must also identify procedure code modifier "NU".

Providers must guarantee the repair work performed for at least 180 days. Repeated requests for repair due to breakage may indicate abuse or neglect. Suspected abuse or neglect may be reported to the department by telephone at 1-844-453-7283, or by visiting the Office of the Inspector General's Report Fraud webpage. Verification of abuse or neglect of the equipment could result in denial of coverage for repairs.

Any questions regarding this notice may be directed to a DME billing consultant in the Bureau of Comprehensive Health Services at 1-877-782-5565, option 3, then option 2.

Theresa A. Eagleson, Administrator

Division of Medical Programs