Presentation on theme: "Presented by Disability Rights California Toll Free: (800) 776-5746 TTY: (800) 781-4546 www.disabilityrightsca.org."— Presentation transcript:
Presented by Disability Rights California Toll Free: (800) 776-5746 TTY: (800) 781-4546 www.disabilityrightsca.org
Medi-Cal puts assistive technology in a number of categories. For example it may be called: medical supplies, durable medical equipment, or a prosthetic device
State law defines medically necessary as: services, medicines, supplies and devices… necessary to protect life, to prevent a significant illness or disability, or to alleviate severe pain. California Welfare & Institutions Code §§ 14059.5, 14133.3
The definition of medical necessity for children is broader than the definition for the regular Medi-Cal program. It includes necessary health care, diagnostic services, treatment, and other measures... to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the state plan. 42 U.S.C. § 1396(r)(5) and 22 C.C.R. § 51184(b).
A written prescription of a licensed practitioner within the scope of his or her practice as established in California law is required for authorization of purchase, rental, repair or maintenance of DME.
For almost all technology, a doctor or medical provider must submit a Treatment Authorization Request (TAR) form that describes why a person needs the requested services, medicine or device. The provider must provide complete justification (i.e. show medical necessity) for the requested device otherwise, it is likely that the device may not be approved.
Provider manual contains specific documentation required for certain equipment. http://files.medi-cal.ca.gov/pubsdoco/Manuals_menu.asp
In our experience, a well written medical necessity letter which explains the connection between the DME and components requested and the recipients disability is very important. It is also important to have the medical professional explain how the DME is the least costly alternative that meets the recipients medical needs. Additional advocacy tips can be found in the Winter 2006 AT Advocate Newsletter article: PREPARING LETTERS OF MEDICAL JUSTIFICATION: Key Components That Will Support the Need for Durable Medical Equipment Through Medicaid and Other Third Party Insurers which can be found at: http://www.nls.org/av/winter06.pdf. http://www.nls.org/av/winter06.pdf
Treatment Authorization Requests (TARs) must be submitted to the appropriate Medi-Cal field office. If a TAR is received in the wrong field office, it will be routed to the correct office. TAR for DME is submitted by the DME provider/vendor.
The Medi-Cal consultant in the field office approves, modifies, defers (for more information) or denies each TAR, depending on Department of Health Care Services (DHCS) policy. After review, an Adjudication Response (AR) is generated and mailed to the address associated with the providers Medi-Cal ID or faxed to the submitting provider.
If the Medi-Cal program does not act on a TAR within 30 days of receiving it, the TAR is deemed to be approved by operation of law. Calendar
A good DME provider makes a difference. Do some research Ask questions (will you consult with me for free; how long in business; how will you make sure that the wheelchair fits in my home; what happens if I have problems with my wheelchair after I receive it…)
Rendering providers of DME shall ensure that all devices and equipment are appropriate to meet the recipients medical needs. If a piece of equipment or a device, when in actual use, fails to meet the recipients needs, and the recipients medical condition has not significantly changed since the device/equipment was dispensed, the rendering provider shall adjust or modify the equipment, as necessary, to meet the recipients needs. The rendering provider, at no cost to the Medi-Cal program, shall replace any equipment or device that cannot be adjusted or modified. CCR, Title 22, Section 51321 (i)
Medi-Cal Fraud Hotline: 1-800-822-6222 Get help to understand your rights: Another vendor Look for help (DRC; ILC) California Lemon Laws
Appeal Rights You should receive a Notice of Action that explains why Medi-Cal is denying request; You have a right to file an appeal within 90 days; If you dont get a notice, you still have a right to appeal;
There are two ways to file for a hearing: 1 st option: You may complete the "Request for State Hearing" on the back of the Notice of Action. Please provide all requested information. Then you may submit your request one of these ways: (1) To the county welfare department at the address shown on the Notice of Action. (2) To the California Department of Social Services, State Hearings Division, P.O. Box 944243, Mail Station 19-37, Sacramento, California 94244-2430. (3) To the State Hearings Division at fax number (916) 229-4110.
2 nd Option: You may make a toll-free call to request a State Hearing at the following number. If you decide to make a request by telephone, you need to be aware that the telephone lines are very busy. California Department of Social Services Public Inquiry and Response Phone 1-800-952-5253 (Voice) 1-800-952-8349 (TDD) NOTE The State Hearings Division cannot accept requests for a state hearing via e-mail. Advocacy tip: Keep a copy of all documents you submit. Also, write down the names of anyone you speak to at the State Hearings Division regarding your request for a state hearing. See, the CDSS State Hearings Division website for more information: http://www.dss.cahwnet.gov/shd/PG1107.htm http://www.dss.cahwnet.gov/shd/PG1107.htm
After you file your appeal, you will receive a letter acknowledging your hearing request. You will eventually receive a date and time for a hearing with an administrative law judge; Medi-Cal is represented by a county representative (non-attorney).
As soon as you get an acknowledgement of your fair hearing request with the hearing number, write to the Medi-Cal field office that denied the TAR. The address is on the TAR denial notice. Ask to review the file and the authority Medi-Cal is relying upon including statutes, regulations and any provisions of the DHS Manual of Criteria and any policy letters.
Seek a good provider; Get help as soon as you know that Medi-Cal said no to your request; Dont miss your appeal deadline. DRC publication: Accessing Assistive Technology in the publications and resources section of website: www.disabilityrightsca.org. www.disabilityrightsca.org
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