Understanding DMEPOS and Medicaid Coverage for Medical Equipment
Learn about Durable Medical Equipment, Prosthetics, Orthotics, and Disposable Medical Supplies (DMEPOS) covered by Nevada Medicaid, including medical necessity criteria. Explore the regulations, coverage areas, and resources available to ensure compliance with DHCFP policies for reimbursement.
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Durable Medical Equipment, Prosthetics, Orthotics and Disposable Medical Supplies DMEPOS 1
Reminder Our policies are updated on a regular and ongoing basis. To assure you are in compliance with DHCFP s policies, always use current versions of all policies. Medicaid Services Manual http://dhcfp.nv.gov/Resources/AdminSupport/Manuals/M SM/MSMHome/ 2
Introduction 42 Code of Federal Regulations (CFR), Section 1902 of the Social Security Act, and Nevada Revised Statutes (NRS) 422.2356 with oversight by Centers for Medicare and Medicaid Services (CMS) the DHCFP reimburses for medically necessary equipment and supplies. Nevada Medicaid covers standard medical equipment that meet the basic medical need of the recipient. meet the basic medical need of the recipient. Products must have been approved by the FDA and be consistent with the approved use. consistent with the approved use. * Products or usage that are experimental or investigational and/or items classified as educational or rehabilitative by nature are non covered. Nevada Medicaid covers standard medical equipment that Products must have been approved by the FDA and be 3
DMEPOS MSM Chapter 1300 http://dhcfp.nv.gov/Resources/AdminSupport/Manuals/MSM/C1300/ Chapter1300/ Billing Guide PT 33 https://www.medicaid.nv.gov/providers/BillingInfo.aspx MSM Chapter 100-Medicaid Program http://dhcfp.nv.gov/Resources/AdminSupport/Manuals/MSM/C100/C hapter100/ Billing Manual https://www.medicaid.nv.gov/providers/BillingInfo.aspx MSM Chapter 3300-Program Integrity http://dhcfp.nv.gov/Resources/AdminSupport/Manuals/MSM/C3300/ Chapter3300/ 4
Coverage Areas Parenteral and enteral nutrition Medical foods Oxygen and oxygen equipment Prosthetics Orthotics Disposable medical supply Mobility 5
Medical Necessity MSM chapter100; section 103.1 A health care product that is provided for under the Medicaid State Plan and is necessary and consistent with generally accepted professional standards to: diagnose, treat or prevent illness or disease; regain functional capacity; or reduce or ameliorate effects of an illness, injury or disability. The determination of medical necessity is made on the basis of the individual case and takes into account: Type, frequency, extent, body site and duration of treatment with scientifically based guidelines of national medical or health care coverage organizations or governmental agencies. Level of service that can be safely and effectively furnished, and for which no equally effective and more conservative or less costly treatment is available. Services are delivered in the setting that is clinically appropriate to the specific physical and mental/behavioral health care needs of the recipient. Services are provided for medical or mental/behavioral reasons rather than for the convenience of the recipient, the recipient s caregiver, or the health care provider. 6
General Information-MSM 1300 Durable Medical Equipment (DME) of a medical nature, needed as a result of a medical condition, and which lasts a considerable time without significant deterioration and appropriate for use within the home, is covered for eligible recipients. Equipment repairs, or replacement requires medical documentation and is subject to limitations of model, cost and frequency. Disposable medical supplies are covered for eligible recipients only if they are necessary for the treatment of a medical condition and would not generally be useful to a person in the absence of an illness, disability or injury. All DMEPOS products and services must be medically necessary, safe and appropriate for the course and severity of the condition, using the least costly and equally effective alternative to meet the recipient s medical needs. Deluxe equipment is not authorized when a standard model will meet the basic medical needs of the recipient. The recipient must have a medical need for each component of the item(s) requested. This includes accessory items and features not included in the standard models of the product. 7
Program Integrity - MSM 3300 MSM section 3303.1.A.2.h Soliciting, receiving, offer or pay any remuneration (including any kickback, bribe or rebate) directly or indirectly, overtly or covertly, in cash or in kind, in return for, or to induce any person to make: 1. Referral of an individual to a provider; 2. Purchase, order, arrange for or recommend the purchase, order of any item, for which payment may be made under the programs operated by the DHCFP; 3. Submit bills or requests for payment containing charges or costs that are substantially in excess of customary charges or costs; 8
EPSDT Early and Periodic Screening, Diagnosis and Treatment Federal program that allows payment for medically necessary equipment and supplies for children under age 21 (up through age 20) Medicaid Services Manual (MSM) 1500 Healthy Kids Program: http://dhcfp.nv.gov/Resources/AdminSupp ort/Manuals/MSM/C1500/Chapter1500/ 9
Provider Responsibility MSM 1303.1.B and 1303.2.B Ensure appropriate for recipient and recipient s residence Provide manufacturer s invoice for zero rate or non-covered items Maintain compliance with Board of Pharmacy and MSM Chapters Maintain records in readily accessible location for at least 6 years from remittance advice MSM section 3303.1.A.2.h 10
PA in Emergency Situations: PT 33 Billing guide Outside of HPES working hours, weekends, on State holidays, dispensing of a 72-hour supply of those DMEPOS items that require prior authorization (PA) can be allowed only: When a delay of 24 hours of treatment could result in very severe pain, loss of life or limb, loss of eyesight or hearing, injury to self, or bodily harm to others; and The treating physician/practitioner indicates a diagnosis that supports the use of the emergency policy. *The supplier must submit the PA the next business day with all required supportive documentation which must include proof of the date and time the order was received by the supplier and documentation to support both in MSM section1303.4 11
Expediting DME PA: guide PT 33 Billing *Staff will review the information as soon as possible and expedite review if necessary to avoid delaying movement to a lower level of care, i.e., discharge from the acute setting to a lower level such as home or to a nursing facility. Call the Prior Authorization Customer Service unit at (800) 525-2395 and notify a representative of the need to expedite a PA. 1. PA number 2. Rationale for need to expedite 12
Provider Rules and Requirements MSM Chapter 100; section 103 Over-utilization, inappropriate utilization, misuse of medical services must be reported by the provider to Medicaid. By accepting Medicaid recipients the provider accepts responsibility to make sure recipient receives all medically necessary services. By accepting Medicaid reimbursement the provider accepts responsibility for their contract and all chapters of the MSM pertaining to their provider type Required to report in writing within 5 working days any changes in address, ownership, or other info pertaining to recipient of Medicaid funds 13
Dispensing and Delivery of Ongoing Supplies MSM Chapter 1300, Section 1303.5 A and B Supplies are dispensed monthly According to physician s orders Subject to coverage limitations Order valid for 12 months Contact with recipient is required for verification of continued need before shipment or reorder, this must be kept in recipient s file. Recipient and provider must have a delivery receipt. 14
Recipient Responsibility MSM 1303.1.C and 1303.4.D Maintaining equipment, keeping clean, keeping maintenance schedule, safe storage when not in use, for example: Misuse, abuse or neglect is prohibited. Returning rented equipment when not needed (recipients can be held financially responsible for not returning equipment). 15
Utilization MSM 1300 Appendix B EVS Authorization Criteria https://www.medicaid.nv.gov/ PT 33 Billing guide - https://www.medicaid.nv.gov/providers/Bill ingInfo.aspx Medicare Noridian Jurisdiction D https://med.noridianmedicare.com/ 16
Medicaid Program MSM 100 Medicaid Program http://dhcfp.nv.gov/Resources/AdminSupp ort/Manuals/MSM/C100/Chapter100/ MSM 3100 Hearings http://dhcfp.nv.gov/Resources/AdminSupp ort/Manuals/MSM/C3100/Chapter3100/ 17
Jessica Vannucci Division of Health Care, Financing, and Policy DMEPOS, Social Services Program Specialist II jessica.vannucci@dhcfp.nv.gov (775)684-3613 Thank you, have a great rest of your day! 18
