Elizabeth Flaherty, RN Barbara Seymour, BSW Health Care Compliance Specialist II 1 Department of Medical Assistance Services.

Elizabeth Flaherty, RN Barbara Seymour, BSW Health Care Compliance Specialist II http://dmasva.dmas.virginia.gov 1 Department of Medical Assistance Services Durable Medical Equipment(DME) Training Presentation

http://dmasva.dmas.virginia.gov/ 2 Department of Medical Assistance Services AGENDA Introduction DME Covered Services and Limitations Certificate of Medical Necessity (CMN/DMAS-352)  Requirements/Time Frames/Exceptions  Completion of CMN General Documentation Requirements Specific DME Guidelines & Documentation Requirements Rent vs. Purchase DME Repairs Service Authorization Pricing Methodology/Billing Quality Management Reviews Resources

http://dmasva.dmas.virginia.gov/ 3 Department of Medical Assistance Services DME Program DME and supplies are a covered services available to the entire Medicaid population. The Department of Medical Assistance Services (DMAS) may cover DME supplies when the individual is under age 21 and the item or supply could be covered under the Virginia State Plan for Medical Assistance (State Plan) through the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT.)

http://dmasva.dmas.virginia.gov/ 4 Department of Medical Assistance Services Freedom of Choice Virginia Medicaid fee-for-service members are free to choose a Medicaid enrolled medical equipment and supply provider when medical equipment and supplies are a covered service. Provision of “free” supplies or items to Medicaid members as an enticement for their business may violate federal law. If a provider is utilizing this practice, DMAS may impose a civil money penalty sanction against the DME provider.

http://dmasva.dmas.virginia.gov/ 5 Department of Medical Assistance Services AGENDA Introduction DME Covered Services and Limitations Certificate of Medical Necessity (CMN/DMAS-352)  Requirements/Time Frames/Exceptions  Completion of CMN General Documentation Requirements Specific DME Guidelines & Documentation Requirements Rent vs. Purchase DME Repairs Service Authorization Pricing Methodology/Billing Quality Management Reviews Resources

http://dmasva.dmas.virginia.gov/ 6 Department of Medical Assistance Services Covered Services and Limitations All medically necessary DME may be covered only if they are medically necessary To carry out a treatment plan prescribed by a practitioner (12 VAC 30-50-165)

http://dmasva.dmas.virginia.gov/ 7 Department of Medical Assistance Services Covered Services – Medical Necessity Medically necessary DME and supplies shall be: Ordered by a practitioner on the CMN/DMAS-352 Ordered by the MEDALLION primary care physician (PCP) or referred for the service by the MEDALLION PCP, if the individual is enrolled in MEDALLION A reasonable and medically necessary part of the individual’s treatment plan

http://dmasva.dmas.virginia.gov/ 8 Department of Medical Assistance Services Covered Services – Medical Necessity Consistent with the individual’s diagnosis and medical condition, particularly the functional limitations and symptoms exhibited by the individual Not furnished for the safety or restraint of the individual, or solely for the convenience of the family, attending physician, or other practitioner or supplier

http://dmasva.dmas.virginia.gov/ 9 Department of Medical Assistance Services Covered Services – Medical Necessity Consistent with generally accepted professional medical standards (i.e. not experimental or investigational) Furnished at a safe, effective, and cost effective level, and Suitable for use in the individual’s home environment

http://dmasva.dmas.virginia.gov/ 10 Department of Medical Assistance Services Covered Services - Limitations Non-covered services can be found in Chapter IV of the DME Medicaid Provider Manual Non-covered DME may be explored for coverage through the EPSDT program( if individual under age of 21) HCPCS Codes not listed in Appendix B does not mean the item is a non-covered item

http://dmasva.dmas.virginia.gov/ 11 Department of Medical Assistance Services Covered Services – Nursing Facilities Requests for coverage of resident specific, customized items for nursing facility residents are made through the DMAS Map-225 process by the nursing facility DME providers can assist in this process by providing the nursing facility with –an invoice reflecting updated national codes –documentation of cost to the DME provider for each code

http://dmasva.dmas.virginia.gov/ 12 Department of Medical Assistance Services Agenda Introduction DME Covered Services and Limitations Certificate of Medical Necessity (CMN/DMAS-352)  Requirements/Time Frames/Exceptions  Completion of CMN General Documentation Requirements Specific DME Guidelines & Documentation Requirements Rent vs. Purchase DME Repairs Service Authorization Pricing Methodology/Billing Quality Management Reviews Resources

http://dmasva.dmas.virginia.gov/ 13 Department of Medical Assistance Services Certificate of Medical Necessity (CMN) Requirements CMN is required for all DME and may be completed by: DME ProviderPhysician Licensed Healthcare Professional The CMN must be: Signed by Practitioner Dated by Practitioner Signed/Dated for DMAS Compliance

http://dmasva.dmas.virginia.gov/ 14 Department of Medical Assistance Services CMN Requirements There must be a completed CMN for all DME supplies/items ordered The physician must sign and date the CMN within 60 days of the begin date indicated on the CMN DMAS will not reimburse the DME provider for services provided prior to the date of the physician’s signature when the signature is not obtained within 60 days of the begin service date (section III of CMN)

http://dmasva.dmas.virginia.gov/ 15 Department of Medical Assistance Services CMN Requirements The CMN allows for up to 12 DME items/supplie s to be listed Multiple CMN’s must be completed if more that 12 items are ordered Blanket orders, i.e., “misc. supplies” are not acceptable

http://dmasva.dmas.virginia.gov/ 16 Department of Medical Assistance Services CMN Requirements The CMN shall not be changed, altered or amended after the attending physician has signed and dated the CMN If changes are necessary, as indicated by the individual’s condition, for the ordered DME or supplies, the DME provider must obtain a new CMN/DMAS-352

http://dmasva.dmas.virginia.gov/ 17 Department of Medical Assistance Services CMN Requirements Alternate versions of the CMN/DMAS- 352 are not accepted Refer to the DMAS web portal for a copy of the CMN/DMAS-352 (www.virginiamedicaid.dmas.virginia.gov )www.virginiamedicaid.dmas.virginia.gov

http://dmasva.dmas.virginia.gov/ 18 Department of Medical Assistance Services CMN Requirements – Length of Certification The CMN Shall be Valid: Maximum period of 6 months Individuals 21 years of age and younger The CMN Shall be Valid: Maximum period of 12 months Individuals older than 21 years of age

http://dmasva.dmas.virginia.gov/ 19 Department of Medical Assistance Services CMN Requirements – Length of Certification DMAS, including service authorization contractor, has the authority to determine a different length of time needed based upon the medical documentation submitted with the CMN. The validity time of the CMN begins with the Begin Date in Section III. If a begin date is not present it begins with the physician signature date. The validity of the CMN shall terminate when the individual’s medical need for the DME or supplies ends.

http://dmasva.dmas.virginia.gov/ 20 Department of Medical Assistance Services CMN Exceptions When the DME service is for nutritional supplements, the CMN/DMAS-352 is valid for six months, regardless of the individual’s age. DMAS may make an exception to the 60-day practitioner signature requirement if retroactive eligibility is determined. All remaining criteria, e.g., fully completed CMN, documentation requirements, and specific coverage criteria, must be satisfied in accordance with the State Plan and DMAS policy guidelines.

http://dmasva.dmas.virginia.gov/ 21 Department of Medical Assistance Services CMN Exceptions A CMN is not required in the following circumstances: Glucose monitor and diabetic supplies for Pregnant Women - Maternity Risk Screen (DMAS - 16) Medicare Primary- If claims come to Medicaid as a crossover claim then a CMN is not required. (Unless denied by Medicare) Note: If the provider knows in advance that Medicare will not cover an item/supply a CMN should be obtained.

http://dmasva.dmas.virginia.gov/ 22 Department of Medical Assistance Services CMN Exceptions Glucose monitor and diabetic supplies for Pregnant Women- Maternity Risk Screen (DMAS-16 ) Medicare Primary – if claims submitted to Medicaid as a crossover claim, a CMN is not required (Unless denied by Medicare!) A CMN is not required in these circumstances

http://dmasva.dmas.virginia.gov/ 23 Department of Medical Assistance Services Completion of the CMN Complete all information in section I Individual Data ID # is the 12 –digit Medicaid ID # A new CMN is not required if this number changes

http://dmasva.dmas.virginia.gov/ 24 Department of Medical Assistance Services Completion of the CMN If questions on left are yes, describe the limitation and how the item treats the medical condition on the right. Refer to documentation guidelines in Chapter IV. Provider may also include this information in the supporting documentation Completing ALL information in Section II assists in describing the medical necessity and helps the provider meet documentation requirements.

http://dmasva.dmas.virginia.gov/ 25 Department of Medical Assistance Services Completing the CMN ICD code is optional – if it is not supplied then clinical diagnosis-narrative MUST be identified Diagnosis MUST be related to item requested Check appropriate line for date of onset

http://dmasva.dmas.virginia.gov/ 26 Department of Medical Assistance Services Completion of the CMN All required sections MUST be completed This is the physician’s order for treatment and requests will be pended, and/or retractions will be made upon post payment review, if this section is incomplete

http://dmasva.dmas.virginia.gov/ 27 Department of Medical Assistance Services Completion of the CMN Begin Service Date – Mo/Day/Year Begin Service date for CMN is optional Starts the time clock for CMN validity time frame If blank, CMN validity begins with physician signature date

http://dmasva.dmas.virginia.gov/ 28 Department of Medical Assistance Services Completion of the CMN HCPCS Code is optional, however the correct code must be submitted for billing. Identify Appropriate HCPCS code using Appendix B Use E1399 if a code is not found in the Appendix B A new CMN is not required if the national code ends during the validity time of the CMN.

http://dmasva.dmas.virginia.gov/ 29 Department of Medical Assistance Services Completion of the CMN Item ordered description (Required Field) Must include a narrative description Should clearly identify each item ordered Each item should be ordered separately on the CMN

http://dmasva.dmas.virginia.gov/ 30 Department of Medical Assistance Services Completion of the CMN Length of time needed (Must be on CMN or in Supporting Documentation signed by physician Identify how long individual needs the DME service Do not confuse with the CMN validity time

http://dmasva.dmas.virginia.gov/ 31 Department of Medical Assistance Services Completion of the CMN Quantity Ordered x 1 Month (Required Field) Should be based upon the quantity required to carry out the physician’s order for the person over the lifetime of the CMN List supplies needed for one month including overages and allowables for one month Durable items: complete total quantity of item needed, e.g. 1, 1 pair, 2.

http://dmasva.dmas.virginia.gov/ 32 Department of Medical Assistance Services Completion of the CMN Quantity/Frequency of Use Justification/ Comment Do not use PRN frequency Ranges many be used, e.g. 7-8 times per day Frequency validates quantity ordered Must be on CMN or in supporting documentation signed and dated by the physician

http://dmasva.dmas.virginia.gov/ 33 Department of Medical Assistance Services Completing the CMN MUST be signed and dated by the physician Physician prescription will not be accepted Ordering physician’s name, printed on form Physician provider number is optional Physician telephone number (include area code) is optional

http://dmasva.dmas.virginia.gov/ 34 Department of Medical Assistance Services Completing the CMN – Page 2 If orders or additional information continue on the back page the physician MUST sign and date this page as well!

http://dmasva.dmas.virginia.gov/ 35 Department of Medical Assistance Services CMN Record Retention The fully completed CMN (and supporting documentation) must be kept in the individual’s record and available for review during an audit Copies of CMN and supporting documentation may be sent to a new servicing provider if required CMN and supporting documentation MUST be maintained for at least 6 years from the date of service

http://dmasva.dmas.virginia.gov/ 36 Department of Medical Assistance Services CMN Record Retention The fully completed CMN and supporting documentation: Must be kept in the individual’s record and available for review during a quality management review Copies of the CMN and supporting documentation: May be sent to a new servicing provider if necessary The CMN and supporting documentation: MUST be maintained in the clinical record for at least 6 years from the date of service

http://dmasva.dmas.virginia.gov/ 37 Department of Medical Assistance Services Agenda Introduction DME Covered Services and Limitations Certificate of Medical Necessity (CMN/DMAS-352)  Requirements for use of CMN  Completion of CMN General Documentation Requirements Specific DME Guidelines & Documentation Requirements Rent vs. Purchase DME Repairs Service Authorization Pricing Methodology/Billing Quality Management Reviews Resources

http://dmasva.dmas.virginia.gov/ 38 Department of Medical Assistance Services General Documentation Requirements These documentation requirements are for all DME and supplies. There must be a fully completed CMN and the documentation must identify on the CMN or the supporting documentation: The medical need for DME The diagnosis related to the reason for the DME request

http://dmasva.dmas.virginia.gov/ 39 Department of Medical Assistance Services General Documentation Requirements Documentation for all DME and Supplies Must Identify: The individual’s functional limitation and its relationship to the requested DME How the DME service will treat the individual’s medical condition How the needs were previously met- identify what changes have occurred which necessitate the DME

http://dmasva.dmas.virginia.gov/ 40 Department of Medical Assistance Services General Documentation Requirements Documentation for all DME and Supplies Must Identify: The quantity needed and why that amount is needed The frequency of use The estimated length of use of the equipment Conjunctive treatment related to the use of the DME/supplies

http://dmasva.dmas.virginia.gov/ 41 Department of Medical Assistance Services General Documentation Requirements Documentation for all DME and Supplies Must Identify: How the service will be used (and is required) within the individual’s home environment, The individual or caregiver’s ability, willingness, and motivation to use the equipment, and Alternatives explored/tried and describe success/failure

http://dmasva.dmas.virginia.gov/ 42 Department of Medical Assistance Services General Documentation Requirements Documentation for all DME and Supplies must identify: Assessments/evaluations from other Healthcare Professionals: – Nurses – Rehabilitative Therapists – Rehabilitative Engineers – Trained DME Professionals All supporting documentation must be signed/dated by the physician

http://dmasva.dmas.virginia.gov/ 43 Department of Medical Assistance Services Requirement for Supportive Documentation Supporting documentation does not replace the requirement of the fully completed CMN The dates on supporting must coincide with the dates of service on the CMN Examples of supporting documentation: physician’s letter, licensed therapist evaluation, etc.

http://dmasva.dmas.virginia.gov/ 45 Department of Medical Assistance Services Requirements for Specific DME

http://dmasva.dmas.virginia.gov/ 46 Department of Medical Assistance Services Guidelines of Specific DME In addition to the Medical Necessity guidelines described in Chapter IV, and the previously discussed documentation requirements for all DME and supplies, specific additional medical justification and/or documentation requirements are in place for the following DME.

http://dmasva.dmas.virginia.gov/ 47 Department of Medical Assistance Services Guidelines and Documentation - Specific DME Wheelchairs Wound Care Supplies Enteral Nutrition Home Infusion Therapy Orthotics  These DME items will be discussed in the upcoming slides

http://dmasva.dmas.virginia.gov/ 48 Department of Medical Assistance Services Guidelines and Documentation – Specific DME Hospital Beds Patient Lifts Augmentative Communication Devices Rehabilitative Equipment Respiratory Equipment Therapeutic Beds and Mattresses  Guidelines regarding these additional specific DME items can be found in Chapter IV, Virginia Medicaid DME Provider Manual, located on the DMAS portal: www.virginiamedicaid.dmas. virginia.gov

http://dmasva.dmas.virginia.gov/ 49 Department of Medical Assistance Services Specific Guidelines - Wheelchairs Specialized or customized wheelchairs may include HCPCS codes in the DME list which do not require service authorization, but that may require a specialty hands on evaluation. Customized equipment is defined as equipment that is uniquely constructed or substantially modified by the provider from the standard product for a specific member according to the description and orders of a practitioner, and in such a way that the equipment can only be used by the specific member. Specialized wheelchairs must have a “hands on” evaluation completed by a licensed health care professional experienced in fitting wheelchairs This evaluation must be signed and dated by the physician

http://dmasva.dmas.virginia.gov/ 50 Department of Medical Assistance Services Specific Guidelines - Wound Care Documentation must include: –The related diagnosis, number of wounds with stages, measurements, and description of the wound –Who is doing the wound care Wound care supplies used during the course of a home health visit are included in the Home Health visit rate

http://dmasva.dmas.virginia.gov/ 51 Department of Medical Assistance Services Specific Guidelines - Enteral Nutrition Coverage is available for nutritional supplements regardless of whether or not the supplement is administered orally or through a Nasogastric or gastrostomy tube Oral coverage however, does not include the provision of “routine” infant formulae For the general Medicaid population, coverage is limited to when the supplement is the sole source form of nutrition and necessary to treat a medical condition

http://dmasva.dmas.virginia.gov/ 52 Department of Medical Assistance Services Specific Guidelines – Enteral Nutrition SOLE SOURCE: 75% or greater of the calories per day come from the enteral nutrition Exceptions include those individuals authorized through the Technology-Assisted Waiver, where the supplement must be the primary source of nutrition, is administered orally or through a nasogastric or gastrostomy tube, and is necessary to treat a medical condition DMAS will reimburse under EPSDT for medically necessary formula and medical foods when used under physician direction to augment dietary limitations or provide primary nutrition to individuals via enteral or oral feeding methods

http://dmasva.dmas.virginia.gov/ 53 Department of Medical Assistance Services Specific Guidelines – Enteral Nutrition Brand name of supplement or category of Enteral nutrition must be documented Provider must supply a specific supplement, if physician ordered one Prior authorization is not required for nutritional supplements

http://dmasva.dmas.virginia.gov/ 54 Department of Medical Assistance Services Specific Guidelines – Enteral Nutrition The CMN/DMAS-352 form is required for all nutritional supplements and supplies regardless of whether or not the individual is enrolled in a waiver program The CMN must specify either a brand name of the supplement being ordered or the category of Enteral nutrition that must be provided. If a physician orders a specific supplement, the DME provider must supply the brand prescribed

http://dmasva.dmas.virginia.gov/ 55 Department of Medical Assistance Services Specific Guidelines – Enteral Nutrition The CMN must be signed and dated by the physician within 60 days of the begin service date If not signed within 60 days of the begin service date, it will be valid on the date of the physician’s signature

http://dmasva.dmas.virginia.gov/ 56 Department of Medical Assistance Services Specific Guidelines – Enteral Nutrition If the physician order changes, a new CMN is required The CMN ordering nutritional supplements is valid for a maximum of six months from the CMN begin service date, regardless of the age of the individual

http://dmasva.dmas.virginia.gov/ 57 Department of Medical Assistance Services Specific Guidelines-Enteral Nutrition A new CMN is required every six months for ongoing nutritional supplement services. The DMAS-115 form is no longer required The required information from the nutritional assessment must be on the CMN or in supporting documentation signed and dated by the physician

http://dmasva.dmas.virginia.gov/ 58 Department of Medical Assistance Services Specific Guidelines – Home Infusion Therapy Definition: Intravenous (IV) administration of fluids, drugs, chemical agents, or parental nutritional substances to individuals in the home setting.

http://dmasva.dmas.virginia.gov/ 59 Department of Medical Assistance Services Specific Guidelines-Home Infusion Therapy Home Infusion Therapy Medically necessary to treat the individual’s medical condition In accordance with accepted medical practice; and Not for the convenience of the individual or the caregiver

http://dmasva.dmas.virginia.gov/ 60 Department of Medical Assistance Services Specific Guidelines – Home Infusion Therapy The individual must: Must reside in either a private home or assisted living facility or group home. Must be under the care of a physician who prescribes the home infusion therapy and monitors the progress of the therapy

http://dmasva.dmas.virginia.gov/ 61 Department of Medical Assistance Services Specific Guidelines – Home Infusion Therapy Must have body sites available for IV catheter or needle placement or have central venous access Must be capable of self-administering or have a caregiver that can be adequately trained, is capable, and willing to administer/monitor home infusion therapy safely and efficiently

http://dmasva.dmas.virginia.gov/ 62 Department of Medical Assistance Services Specific Guidelines – Home Infusion Therapy The home IV payment methodology is not applicable to: Subcutaneous delivery Intramuscular delivery Clysis delivery Site care Enteral/Foley care

http://dmasva.dmas.virginia.gov/ 63 Department of Medical Assistance Services Specific Guidelines - Orthotics Includes the services necessary to design the device, including measuring, fitting, and instructing the individual in it’s use. Orthotic coverage includes devices that support or align extremities to prevent or correct deformities, or improve functioning.

http://dmasva.dmas.virginia.gov/ 64 Department of Medical Assistance Services Specific Guidelines - Orthotics Orthotics, including braces, splints, and supports, are not covered for the general adult Medicaid population under the DME program, with the exception of coverage while participating in an inpatient Intensive Rehabilitation program All medically necessary orthotics are covered for children under the age of 21 years through the EPSDT program

http://dmasva.dmas.virginia.gov/ 66 Department of Medical Assistance Services Rent vs. Purchase RENTAL SHORT-TERM USE CONDITION IS EXPECTED TO CHANGE APPENDIX B IDENTIFIES THE RENTAL CODES AND DEFINES THE LENGTH OF TIME CONSIDERED TO BE SHORT-TERM PURCHASE LONG-TERM USE CONDITION IS NOT EXPECTED TO CHANGE RELATIVE TO THE LENGTH OF TIME THE DME SERVICE IS ORDERED ON THE CMN

http://dmasva.dmas.virginia.gov/ 67 Department of Medical Assistance Services Rental vs. Purchase DMAS will NOT pay for rental days that DME service/item is not used by the individual Rental beyond the allowable limits in the DME Listing requires service authorization When it is determined a DME item was rented; however, should have been purchased DMAS will only provide reimbursement up to the established purchase price

http://dmasva.dmas.virginia.gov/ 68 Department of Medical Assistance Services Rental vs. Purchase There are rental/purchase guidelines in the Manual for specific DME items: –Apnea Monitors –CPAP –TENS Units –Augmentative Communication Devices DMAS requires documentation of individual’s benefit and compliance

http://dmasva.dmas.virginia.gov/ 70 Department of Medical Assistance Services DME Repairs The cost to repair rental equipment is considered the DME provider’s responsibility Charges for repair(s) to medically necessary, individual owned equipment may be billed to DMAS using the proper DMAS HCPCS code. The provider should document in the individual’s record if the equipment is individual owned Labor charge is for repairing the equipment and not administrative service or driving time to/from the individual’s home

http://dmasva.dmas.virginia.gov/ 71 Department of Medical Assistance Services DME Repairs The provider must accept Medicaid payment as payment in full, and may not bill the individual for any portion of the repair, including shipping and handling charges.

http://dmasva.dmas.virginia.gov/ 73 Department of Medical Assistance Services Service Authorization Service authorization (SA) is the process to approve specific services for an enrolled Medicaid, FAMIS Plus or FAMIS individual by a Medicaid enrolled provider prior to service delivery and reimbursement. Some services do not require SA and some may begin prior to requesting authorization.

http://dmasva.dmas.virginia.gov/ 74 Department of Medical Assistance Services Service Authorization-Purpose The purpose of service authorization is to validate that the service requested is medically necessary and meets DMAS criteria for reimbursement. Service authorization does not guarantee payment for the service nor does it supersede any of the documentation requirements.

http://dmasva.dmas.virginia.gov/ 75 Department of Medical Assistance Services Service Authorization Payment is contingent upon passing all edits contained within the claims payment process, the individual’s continued Medicaid eligibility, the provider’s continued Medicaid eligibility, and ongoing medical necessity for the service. Service authorization is specific to an individual, a provider, a service code, an established quantity of units, and for specific dates of service.

http://dmasva.dmas.virginia.gov/ 76 Department of Medical Assistance Services Service Authorization The DMAS SA contractor has information related to the service authorization processes for all Medicaid programs they review Fax forms, service authorization checklists, trainings, methods of submission and much more are on KEPRO’s website. Providers may access this information by going to: http://dmas.kepro.com

http://dmasva.dmas.virginia.gov/ 77 Department of Medical Assistance Services Service Authorization – Appeals Reconsiderations for denied service authorizations must be requested and mailed to DMAS within 30 days of the denial to the unit performing the preauthorization function Appeals of adverse reconsiderations may be mailed within in 30 days of the denial to: Director, Appeals Division 600 East Broad Street Richmond, VA 23219

http://dmasva.dmas.virginia.gov/ 79 Department of Medical Assistance Services Pricing Methodology/Billing DME items that: Have a national code and a set fee the rate will be the Medicare Competitive Bid Rate, if available or the DMERC rate minus 10% Have a July 1, 2010 rate, but do not have a national code, bill the E1399 miscellaneous code. The rate will be the posted in the Appendix B

http://dmasva.dmas.virginia.gov/ 80 Department of Medical Assistance Services Pricing Methodology/Billing DME items that: Have a national code, but no DMERC or July 1, 2010 rate - the rate will be Individual Consideration (IC) = provider’s cost, minus shipping and handling charges, plus 30% Documentation in individual’s record must show the provider’s cost on an invoice from manufacturer or supplier (a quote is not acceptable for final documentation).

http://dmasva.dmas.virginia.gov/ 81 Department of Medical Assistance Services Pricing Methodology/Billing DME items that: Do not have a national code, or a July 1, 1996 rate, the E1399 miscellaneous code will be used; the rate = manufacturer’s cost (to the provider) plus 30% Documentation in individual record must show the provider’s cost via invoice from manufacturer or supplier

http://dmasva.dmas.virginia.gov/ 82 Department of Medical Assistance Services Billing Changes If a member has a primary insurance and the provider asserts the item is not covered by the primary insurance the provider must bill the primary insurance at least 1 time and then attach the EOB to all claims – regardless of how long the item is supplied by the provider.

http://dmasva.dmas.virginia.gov/ 84 Department of Medical Assistance Services Quality Management Reviews (QMRs) The Department of Medical Assistance Services routinely conducts compliance reviews to ensure that the services provided to Medicaid members are medically necessary and appropriate and are provided by the appropriate provider. These reviews are mandated by Title 42 C.F.R., Part 455

http://dmasva.dmas.virginia.gov/ 85 Department of Medical Assistance Services QMR – Provider Review DMAS’ contractors will be conducting on-site or desk review activities throughout the state!

http://dmasva.dmas.virginia.gov/ 86 Department of Medical Assistance Services QMR – Provider Responsibility Providers are to: Verify individual’s Medicaid eligibility Obtain SA when required Deliver only item(s) ordered by the physician on the CMN/DMAS-352 Deliver only the quantities ordered by the physician on the CMN/DMAS-352 Deliver only the item(s) for the periods of service covered on the physician’s order

http://dmasva.dmas.virginia.gov/ 87 Department of Medical Assistance Services QMR – Provider Responsibility Providers are to: Maintain physician’s order and supporting documentation Document and justify the description of services Document all equipment and supplies provided to an individual in accordance with physician’s order

http://dmasva.dmas.virginia.gov/ 88 Department of Medical Assistance Services QMR – Provider Responsibility Document of service provision The delivery ticket must document the: –Individual name –Date of delivery –Item/supply was delivered – to include accessories to primary item ordered on CMN –Quantity delivered

http://dmasva.dmas.virginia.gov/ 89 Department of Medical Assistance Services QMR – Retractable Issues DMAS will deny or retract payment when the following occur: Invalid CMN/DMAS-352 Documentation does not verify the item/supply was provided Lack of medical documentation to justify provision of the DME DME item does not meet DMAS criteria

http://dmasva.dmas.virginia.gov/ 90 Department of Medical Assistance Services QMR – Top Discrepancy Issues CMN: Missing / Invalid / Incomplete / Expired / Outdated or Altered Insufficient medical documentation Service provided in excess of physician’s order/CMN Medical necessity not justified Service delivery not documented

http://dmasva.dmas.virginia.gov/ 91 Department of Medical Assistance Services QMR – Top Discrepancy Issues Item not covered or does not meet DMAS coverage criteria Items rented vs purchased Frequency does not justify quantity provided

http://dmasva.dmas.virginia.gov/ 92 Department of Medical Assistance Services QMR – Top Discrepancy Issues Supplying two different mobility devices on the same date without documentation to support each device Services included in other program reimbursement (standard parts, home health nursing, etc.) Billing for supplies used outside the home (M.D. office or home health clinic)

http://dmasva.dmas.virginia.gov/ 93 Department of Medical Assistance Services QMR – Top Discrepancy Issues Enteral Nutrition Policy: –Failure to obtain a new CMN every six months –Nutritional assessment information is missing from CMN or no supporting documentation –Improper calculation of units for billing –Not following policy of “sole source” of nutrition for adults

http://dmasva.dmas.virginia.gov/ 94 Department of Medical Assistance Services QMR –Provider Appeals A provider may appeal an adverse decision where a service has already been provided, by filing a written notice for a first-level Informal Appeal with the DMAS Appeals Division within 30 calendar days of the receipt of the adverse decision.

http://dmasva.dmas.virginia.gov/ 95 Department of Medical Assistance Services QMR – Provider Appeals If a provider is dissatisfied with first-level decision, the provider may file a written notice for a second-level appeal. The notice for a second-level Formal Appeal must be filed within 30 calendar days of receipt of the first-level Informal Appeal decision.

http://dmasva.dmas.virginia.gov/ 96 Department of Medical Assistance Services Provider Appeals The notice(s) of appeal is considered filed when it is date stamped by the DMAS Appeals Division. The notice must identify the issues being appealed. Notices of Appeal must be sent to: Appeals Division Department of Medical Assistance Services 600 East Broad Street, 6 th Floor Richmond, VA 23219

http://dmasva.dmas.virginia.gov/ 98 Department of Medical Assistance Services Contact Information Division of Long Term Care Fax number: 804-612-0050 Address: DMAS-Division of Long Term Care 600 East Broad Street Richmond, Virginia 23219

http://dmasva.dmas.virginia.gov/ 99 Department of Medical Assistance Services Medicaid Resources Web Site: www.dmas.virginia.gov Web Portal: www.virginiamedicaid.dmas.virginia.gov www.virginiamedicaid.dmas.virginia.gov These sites provide a wealth of information to providers and provides access to such resources as: manuals, memos, training presentations, and provider forms.

http://dmasva.dmas.virginia.gov/ 100 Department of Medical Assistance Services Medicaid Resources DMAS has a dedicated email address specifically for providers for questions about DME. (dme@dmas.virginia.gov)dme@dmas.virginia.gov This is not a secure email so please do not include individual specific information.

http://dmasva.dmas.virginia.gov/ 101 Department of Medical Assistance Services Medicaid Resources E-mail questions should pertain to polices, codes, or rates and should not pertain to SA, billing, or claims. Please refer these questions to the appropriate unit. Service Authorization Contact Information: Kepro - 888.827.2884 or via email at ProviderIssues@kepro.org or PAUR06@dmas.virginia.gov ProviderIssues@kepro.org PAUR06@dmas.virginia.gov Billing/Claims – Call the helpline at 800-552-8627.

http://dmasva.dmas.virginia.gov/ 102 Department of Medical Assistance Services DME Presentation Thank You! Elizabeth Flaherty, RN Barbara R. Seymour, BSW

Elizabeth Flaherty, RN Barbara Seymour, BSW Health Care Compliance Specialist II 1 Department of Medical Assistance Services.

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Elizabeth Flaherty, RN Barbara Seymour, BSW Health Care Compliance Specialist II 1 Department of Medical Assistance Services.

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