FROM: Paul Swatsenbarg, Deputy Administrator
1. Prior-Authorization by cost rather than units.
Adult DD Services will no longer be prior authorized by units. Prior authorization will be entered by the cost of the service in dollar amounts. The PA notice sent to providers will identify the total dollar amount authorized for the plan year. Providers will need to bill services according to frequency described on the ISP, to insure that authorized dollar amounts are not used up before the end date of the ISP. Prior authorization will be based on the costing sheet calculation for each service for the full plan year. This will provide flexibility for participants and providers to accommodate unique or special circumstances.
2. Prior-Authorization for Medical Social History performed by a DDA.
A Developmental Disabilities Agency may complete and be reimbursed for a Medical Social History that conforms to the requirements of IDAPA 16.04.11 (Rules Governing Developmental Disabilities Agencies. A Medical Social History will not be authorized in order to evaluate the need for psychotherapy. Participants assessed by the Independent Assessment Provider under IDAPA 16.03.13. will have a Medical, Social and Developmental History completed by the Assessor that will be available to the DDA as required by (IDAPA 16.04.11.800.01.b.). DDAs should utilize the information in that document to minimize duplicative efforts to complete a Medical/Social History Evaluation.
3. Contents and Distribution of an ISP packet.
An ISP packet should include the following information:
• Medical Care Evaluation Form
• Health and Well Being Form
• Residential Habilitation Program Coordination Plans for both Certified Family Home or Supported Living, and
• All ISP forms.
The information in the ISP packet must be provided to the Department to authorize the services on the ISP.
Distribution: Plan Developers are responsible for the distribution of the ISP documents as requested from the identified providers on the ISP.
4. Two ways to bill for Plan Development (G9007) and Plan Monitoring (G9012)
An agency that provides plan development and plan monitoring may choose between two options to bill for these services. The agency must adopt one method for all claims.
1. Delineate the service by each date of service as a separate line item on the claim.
2. Use a date span within the same month for the date of service. The units and dollars will reflect the total amount within the date span. Documentation of the daily activity must be documented within the agencies progress notes for each day of service delivery.
5. Modifications to DME/SME Guidelines
• When it is determined that the participant needs any medical equipment or supplies during the participant’s negotiated budget meeting/person centered planning meeting, the Plan Developer will consult with the medical equipment vendor to determine whether the requested equipment/supplies are covered under Medicaid’s DME and require prior authorization.
• If prior authorization is not required, you may select a Medicaid DME vendor through the person centered planning team process and consult with that vendor for the price and appropriate code. Use the vendor “quote” for the cost of the DME supply or equipment on the ISP and submit the plan to the Assessor. The Assessor will use the participant profile to validate the cost.
• If prior authorization is required, the request including the procedure codes and prices is submitted by the medical equipment vendor to the DME unit in the Care Management Bureau.
• To assure the authorization is completed by the DME unit, the Plan Developer must get a valid price from the vendor and obtain a copy of the AIM prior authorization notice prior to putting the supply or equipment on the ISP.
• The authorization must be completed by the DME unit prior to the ISP being submitted. The Plan Developer must submit a copy of the prior authorization notice along with the ISP to the Assessor.
The guidelines are attached.
6. Modifications to Guidelines for Authorization of Medical Transportation
• Plan Developers will work with Commercial Transportation providers to identify the mileage and amount (miles per week) authorized.
• For participants with an adult DD ISP, the Medical Transportation unit will contact the appropriate Assessor with any questions.
• The Assessor will contact the appropriate Medical Transportation specialist with any questions regarding medical transportation requests.
If you have any questions concerning the information contained in this release, please contact Jean Christensen by phone at 208-364-1828 or e-mail: christej@idhw.state.id.us.
Thank you for your continued participation in the Idaho Medicaid Program.
____________________________________________________________________
Guidelines For Plan Developers, Department Staff and Assessors for Durable Medical Equipment and Supplies (DME) Specialized Medical Equipment and Supplies (SME) For DD and ISSH Waiver Participants
Plan Developers and Department Staff
Plan Developers are responsible for assisting individuals requesting developmental disabilities services to obtain needed medical equipment and supplies and to submit plan of service authorization requests and addendum for costing. The following guidelines are to assist the Plan Developer in assuring these services for the participant are authorized and captured in the ISP in the most expedient manner.
It is important to remember that if the participant you are providing services to is enrolled with the Healthy Connections Program, a primary care provider referral is necessary for Medicaid reimbursement of Durable Medical Equipment and Supplies (DME) or Specialized Medical Equipment and Supplies (SME). You are responsible for assuring that this referral is obtained prior to requesting Medicaid reimbursement for DME or SME.
State Plan Durable Medical Equipment (DME)
When you have determined that the participant needs any medical equipment or supplies during the participant’s negotiated budget meeting/person centered planning meeting, the Plan Developer will consult with the medical equipment vendor to determine whether the requested equipment/supplies are covered under Medicaid’s DME and require prior authorization.
§ Copies of DME rules are available through the IDAPA rules 16.03.09.106.
§ Refer to the DME provider handbook for items requiring prior authorization from the DME specialist in the Department. If there are questions call 1-866-205-7403.
§ If you know the procedure code for the item you may call EDS at 383-4310 or 1-800-685-3757.
§ If the equipment/supplies are not covered under the State Plan and the individual is either receiving or applying for waiver services, you should follow the procedure for Specialized Medical Equipment and Supplies (SME) listed below.
§ If requests for non-covered equipment and/or supplies are submitted to DME Specialists, they will automatically consider any equipment/supplies under SME and refer the request to the appropriate Assessor for processing.
§ Once you determine that the equipment/supplies are covered under Medicaid, please use the following protocol for submitting the plan of service that include DME:
• If no prior authorization is required, you may select a Medicaid DME vendor through the person centered planning team process and consult with that vendor for the price and appropriate code. DME suppliers are listed in the yellow pages in your region under “Medical Equipment and Supplies.” Use the vendor “quote” for the cost of the DME supply or equipment on the ISP and submit the plan to the Assessor. The Assessor will use the participant profile to validate the cost.
• You may need to assist the vendor (the vendor must be an Idaho Medicaid DME provider) in obtaining any needed additional information to be submitted to the assessor.
• If there are questions in regards to DME authorizations, contact the DME unit in the Care Management Bureau.
§ If a participant is currently living in an ICF/MR or is applying for waiver services and will need either DME or SME immediately upon discharge/approval onto the DD or ISSH waiver, the needed items may be requested by the vendor prior to discharge/approval. However, the actual authorization cannot be given until the participant is discharged.
§ The authorization of the plan and/or the discharge from the facility should not be delayed waiting for authorization of DME or SME unless the equipment is essential to their discharge into the community. If the person cannot be discharged without the equipment, validation that the authorization will occur must be done prior to that discharge.
§ For DME supplies not requiring prior authorization from the DME unit, the Plan Developer should attempt to get the prices from the available lists, DME Medicaid Care Management, medical equipment vendor or the Voice Response System 1-800-685-3757, and submit the plan to the Assessor with an estimate of the costs.
Specialized Medical Equipment and Supplies (SME) - DD and ISSH Waivers Only
§ Prior to requesting SME the Plan Developer or service coordinator (TSC) must first attempt to access these services through all other resources. In addition, the Plan Developer or service coordinator must provide documentation from a professional validating the need of the requested equipment specific to the participant.
§ SME does not include convenience items or devices to assist the provider in fulfilling their responsibilities as outlined in Rule due to a disability or deficit of the provider.
§ The procedure code used to bill Specialized Medical Equipment and Supplies is E1399.
§ Requests for SME supplies will come through the Assessor for review on the ISP.
§ This code can not be used to bill for Durable Medical Equipment or for participants that are not eligible for services on the DD or ISSH waivers.
§ If there are questions in regards to SME on the ISP, contact the Assessor.
Select an Idaho Medicaid vendor
§ If the only vendor for the SME is not an Idaho Medicaid DME vendor they will have to become a vendor prior to requesting authorization for services.
§ The vendor should contact the Assessor to apply for SME provider status or EDS to apply for DME vendor status.
§ To provide DME, the provider must enroll type 014 with the specialty of 137 or 138.
§ To provide DME and SME you may enroll as specialty 137 or 138.
§ To provide services under the waiver vender definition, you must enroll as specialty 141.
§ The Plan Developer must submit documentation of efforts to find other funding and/or natural/informal supports to the Assessor in their region.
§ If technical assistance is needed to determine the type of information needed to justify the need for DME or in processing the request for DME, please contact the DME Specialist in Medicaid using the information below.
DME Specialists, Care Management Bureau
Address: Phone Number: FAX Number:
PO Box 83720 1-800-352-6044 1-866-205-7403
Boise, Idaho 83720-0036
Dorrie Phillips Cille Lasley
Perinatal PA Wheelchair PA
- Apnea monitor Walker PA
- Bili lights AIM UAT
- Oximeter Creditable Health Insurance Determination
- Breast pumps Gait Trainers
DME Claims Adjudication Standers
Communication Devices Hospice Program
Excess Supplies
Nutritional Supplies
Miscellaneous
Home Health
Steve Brown Dee Patterson Linda Schrock
CPAP/BIPAP PA Bone Growth Simulator PA Diabetic Supplies
Vest PA TENS Units PA - Insulin pumps
Semi-Electric Bed and Mattress Hearing Aids - Supplies in excess
Wound Vac PA - Glucose monitors
Ventilators
CPM Machines
Elastometric Devices
Bathroom Equipment
§ Once you select a vendor who can provide the needed item, the vendor must submit a request form for prior authorization along with the following documentation:
· Name of item (product), including make and model
· Retail price of item
· Vendor’s cost of item (quote) or manufacturer’s pricing sheet if the code is manually priced
· Medical Necessity documentation will include a description of the item, why needed, functional abilities, what less costly means of meeting the medical need have been considered and the reasons each would not meet the medical need, and how it will be used.
§ For questions concerning policy issues and SME contact: Regional Assessor
Assessor
DME
§ All requests for DME will be reviewed by the Assessor as part of the overall cost of the ISP using the following tools:
· Participant profile
· Medicaid Fee Schedule on www.idahohealth.org
· DME Equipment and Supply Cost list
§ The Plan Developer is responsible for obtaining the appropriate cost, code and copy of the prior authorization notice prior to the submission of the ISP.
§ The Assessor can use the profile to validate DME supplies or equipment cost from past years expenditures when relevant.
§ Any request denied by the DME unit must not be included in the plan submitted to the Assessor for review.
§ If a DME supply requires prior authorization from the DME unit, a copy of the prior authorization notice must be submitted with the ISP to the Assessor. Any ISP’s with DME requiring prior authorization not accompanied with a notice will be taken off the plan and will not be considered part of the cost. The Assessor will notify the Plan Developer when this occurs.
SME
§ The Assessor will prior authorize the SME request as part of their plan of service authorization process.
§ The Assessor will rule out a DME request by using the DME code list and Medicaid Fee Schedule.
§ If the Assessor is unsure about the SME request, contact the DME specialist to clarify the request.
GUIDELINES FOR AUTHORIZATION OF MEDICAL TRANSPORTATION
1. All requests for Medical Transportation (by an individual or agency transporter) over 21 miles will come to the Transportation unit for review, and authorization in AIM. (Business as usual). Commercial transporters must prior authorize ALL trips regardless of mileage.
2. The Behavioral Health unit will provide a list of adults with developmental disabilities and their plan of service dates to the Transportation unit. They will use it as reference material but will not have time to refer to it in daily business.
3. Plan Developers will work with the Commercial Transportation providers to identify the type and amount authorized by the Transportation unit.
4. Transportation costs are being calculated as part of the overall cost of the plan in the implementation of Care Management for adult DD. They will be included in the Participant Profile as part of the past expenditures.
5. The Assessor must review the medical transportation request to assure the participant is being transported to the nearest DDA, is cost effective, and reflects the participant’s assessed needs.
6. For participants with an adult DD ISP, the Medical Transportation unit will contact the appropriate Assessor with any questions.
7. The Assessor will contact the appropriate Medical Transportation specialist with any questions regarding medical transportation requests.
Region 1 & 3 Carla T 208-287-1171 turleyc@idhw.state.id.us
Region 2 & 4 Christine F 208-287-1172 fennerc@idhw.state.id.us
Region 5, 6 & 7 Sara H 208-287-1173 hunts@idhw.state.id.us
______________________________________________________________