Durable Medical Equipment (DME) is any equipment that provides therapeutic benefits to a patient in need because of certain medical conditions and/or illnesses. DME consists of items which are primarily and customarily used to serve a medical purpose. The equipment and supplies must be the most reasonable and cost effective treatment to meet the participant’s medical needs. Medicaid will cover these items for the participant to use in the home, community or living under a home health agency plan of care that meets the requirements found in the state rules.
The Medical Care Unit (MCU) reviews those DME items which require a prior authorization (PA). Please see the most recent Fee Schedule to determine if an item requires a PA. MCU will not authorize a PA if one isn’t required. MCU reviews items covered under 1905A benefits and will also consider requests under EPSDT on a case-by-case basis if not covered by traditional Medicaid.
Medical necessity rationale must be submitted with the request. Department standards for medical necessity are those national standards set by the Centers for Medicare and Medicaid Services (CMS) in the Medicare DME MAC Jurisdiction D Supplier Manual. Medical necessity rationale may be demonstrated by a letter of medical necessity, physician notes, or therapy notes. All requests require a prescription signed by a doctor, nurse practitioner, or physician assistant. No verbal orders or stamped signatures will be accepted. Refer to the Provider Handbook, Suppliers, to learn about specific documentation requirements for common items.
The status of a prior authorization request may be checked online at the Molina Health PAS portal under “Authorization Status”, using your NPI, or by contacting Molina at (866) 686-4272. If you have questions on a Denial, click on the Notes, which will explain the reason for the Denial, or ask the Molina Customer Service Representative to read you the Notes in the Denial.
Frequently Asked Questions can answer most of your DME questions. If you have further questions you can email our DME Representative.