Provider Notice issued 06/08/06

Power Mobility Devices and Custom Manual Wheelchairs

Effective July 1, 2006, prior approval requests for PMDs and custom manual wheelchairs must include these forms and will not be processed until all information is received from the ordering physician, a licensed physiatrist or physical/occupational therapist (chosen by the physician) and the Durable Medical Equipment (DME) provider. Information must be complete, legible, dated and signed by the appropriate provider or the request will be returned. These forms are to be used by medical providers instead of narrative letters of medical necessity; however, narrative statements must be used when comments are requested on the forms and for medical justification of requested accessories.

The department relies on DME providers to ensure that all the information required on the forms is collected from the medical providers, checked for completeness, legibility and mailed (not faxed) to the department with the order, product information and pricing. Therefore, it is recommended that DME providers forward a copy of this provider notice and the appropriate forms to the medical providers for their use. A request for additional information or a return of an incomplete or invalid request will be made to the DME provider for appropriate disposition.

The HFS 3701H and 3701K forms and information on documentation required when requesting PMDs and custom manual wheelchairs can be found on the department’s Web site at:

www.hfs.illinois.gov/medicalforms/

If you have questions regarding this notice, please contact the Bureau of Comprehensive Health Services at 1-877-782-5565.

Anne Marie Murphy, Ph.D.

Administrator

Division of Medical Programs

The following identifies the documentation needed by the department in order to process requests for power mobility devices and custom manual wheelchairs:

Ordering Physician  

• A completed HFS 3701K (N-4-06) form titled “Power Mobility Devices (PMD) and Custom Manual Wheelchairs,” after a face-to-face evaluation of the patient.  

• A signed, dated order for all requested equipment, including accessories, with brief, narrative medical justification (not the function of the item) for each requested item - (documentation of medical necessity can be delegated to the evaluating physiatrist or physical/occupational therapist but must be reviewed, co-signed & dated by the ordering physician, who should indicate if he/she has any disagreement with specific findings or recommendations). The physician is responsible for arranging the physiatrist/physical/occupational therapy evaluation. The evaluator must be licensed and conduct the evaluation face to face. In those rare instances when a physiatrist or physical/ occupational therapist is not available, the physician may complete the evaluation with department approval. Multiple-paged physician orders must have either the patient’s name or the physician’s signature on each page.

Physiatrist or Physical/Occupational Therapist:  

• Documentation of a face-to-face, hands-on evaluation of the patient (in association with a mobility device specialist) by a licensed physiatrist or physical/ occupational therapist (that is to be reviewed and co-signed by the ordering physician) and includes a recommendation for the optimal mobility equipment to serve the patient for the next five-to-six (5-6) years. 

• A completed HFS 3701H (R-4-06) form titled “Seating/Mobility Evaluation." The therapist must complete and sign a checklist (on the form) of any affiliation with the Durable Medical Equipment provider, the manufacturer of the ordered equipment, or a long term facility that is the recipient’s residence.  

• The minimum equipment to meet the patient’s needs should be recommended, cost effectiveness must be a high priority consideration and judgment must be applied to ensure that the recommended equipment can be modified to meet the changing needs of a patient who has a condition characterized by deterioration, or who is growing in stature and/or is gaining weight.

Durable Medical Equipment (DME) Provider

• Submit order on Form DPA 2240 via mail only – faxed requests will be returned. Please do not enter orders for base andaccessories separately in multiple boxes on the form. When entering the order in box1 on the form, specify the HCPCS code for the wheelchair base, if wheelchair base only is ordered, or if accessories are included with the base price. If accessories are not included with the base, order as K0014 or K0009 for a power wheelchair or custom manual wheelchair respectively, and list each ordered item on a separate itemized price list.  

• The DME provider’s itemized price list must include: HCPCS code and manufacturer’s pricing information including MSRP, and provider’s acquisition cost (excluding taxes and shipping)for each requested item. A column showing provider’s price may be included, however, HFS payment will be based upon the MSRP, the provider’s acquisition cost, or Medicare allowable. This provider’s itemized price list is separate from, and additional to, the pricing information shown on the manufacturer’s product pricing sheets that must be included with the order.  

• The manufacturer’s product information including pricing, descriptions of the base and major components plus specifications showing the maximum user weight capacity, dimensions, and seating measurements of the mobility device that has been ordered. The manufacturer’s pricing information must include the MSRP, the charge to the provider (excluding taxes and shipping charges), and the HCPCS code for each ordered item and must be on the manufacturer’s letterhead. If the provider is constructing a component such as a seating system, the pricing information must show a breakdown of material and labor costs.  

• DME provider will check the medical providers’ information for completeness and legibility and, if satisfactory, forward to HFS with the order. The order must be received by HFS within ninety (90) days of the date of the physician’s order.  

• A signed statement from the DME provider that states: “If prior approval is given, we will supply to the named recipient the equipment and accessories shown on the order form and the itemized price list and this equipment meets the patient’s medical need at the time of delivery.”

All the above referenced documentation is to be mailed to the following address:

Illinois Department of Healthcare and Family Services

Bureau of Comprehensive Health Services

Attn: Prior Approval Unit

P.O. Box 19124

Springfield, IL 62763-0002

• HFS 3701H (pdf)

• HFS 3701K (pdf)