Provider Notice Issued 05/18/2017

Durable Medical Equipment (DME) Prior Approval Process with Transition from Managed Care Organization (MCO) to Healthcare and Family Services (HFS)

Date:  May 18, 2017

To:      All Medical Assistance Providers

Re:     Durable Medical Equipment (DME) Prior Approval Process with Transition from Managed Care Organization (MCO) to Healthcare and Family Services (HFS)

          Fee-for-Service

This notice clarifies information needed by Health Care and Family Services (HFS) in order to efficiently process prior approval requests when participants transition from an MCO to HFS fee-for-service (FFS). Submission of required information with the initial prior authorization request helps to ensure timely processing.

If an item is approved on a rent-to-purchase basis when a participant is in an MCO and the participant’s eligibility changes to FFS prior to the item reaching purchase, providers must request approval through HFS for the timeframe when the participant has FFS eligibility. HFS will review requests only for the timeframe that remains until the item is considered patient-owned. Providers should refer to the DME Fee Schedule and Key for information regarding prior approval requirements, quantity limits, and timeframes.

In order to process prior approval requests, HFS requires exact information as to when the item was delivered to the participant and the remaining months of rental before the item is considered purchased.  The HFS1409 Prior Authorization Request Form (pdf) line 21, Additional Medical Necessity should identify the delivery date of the item.

The following information must also be submitted with prior approval requests:

·       HFS 1409 line 21dated to match delivery ticket .

·       Copy of the original practitioner order with signature and date.

·       Medical documentation to support the rental of the equipment (i.e. sleep studies, etc.)

·       HFS required questionnaires completed by the ordering practitioner.

Requests received without all the required information will delay processing.

It is imperative that providers verify participant eligibility prior to dispensing items. Electronic Data Interchange vendors, the Automated Voice Response System (AVRS) at 800-842-1461 and the Medical Electronic Data Interchange (MEDI) system to identify any care coordination plan in which the participant is enrolled in. Additional information can be found at the HFS Care Coordination webpage.

Prior approval requests and all documentation should be faxed to 217-524-0099. Additional information requested by HFS, should be faxed to the HFS Review Fax Line, 217-558-4359.

DME prior approval questions may be directed to the Bureau of Professional and Ancillary Services at 217-524-0009.

Felicia F. Norwood
Director