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Elizabeth M. Whitehorn, Director

Provider Notice issued 06/16/11

Information Request to Determine Reimbursement for DME Prior Approvals

To:​ Enrolled Durable Medical Equipment and Supplies (DME) Providers​
​Date: ​June 16, 2011
​Re: Information Request to Determine Reimbursement for DME Prior Approvals​

This notice pertains to prior approval requests for items such as bases and components for new power and manual mobility devices; repairs and modifications to mobility devices; other durable medical equipment and supply products; orthotic/prosthetic items; and hearing aid supplies. 

Effective with prior approval requests received on and after August 1, 2011, the department will require providers to submit their actual cost, defined as dealer acquisition cost for the purposes of this notice, as well as manufacturer’s suggested retail pricing (MSRP), for each item. Dealer acquisition cost, referred to as wholesale price in 89 Ill. Admin. Code section 140.481, and MSRP must be verified by a manufacturer’s or wholesaler’s cost statement and catalog pricing, respectively. Quotes are not acceptable substitutes for MSRP unless catalog pricing is not available. Reimbursement may be determined by pricing for widely accepted and available quality items comparable to the requested item.

Medical documentation and justification must accompany the prior approval request. If a provider submits a request without a statement of medical necessity and figures for cost and MSRP, the department will return the request due to insufficient information.

Any questions regarding this notice may be directed to the Prior Approval Unit at 217-524-0009.

 

Theresa A. Eagleson, Administrator

Division of Medical Programs