2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix F. Prior Authorization GuideCovered Servicesdiagnostic imaging andtherapeutic radiologyservices (for imaging)dialysis servicesdurable medical equipment(DME) and suppliesIs PriorAuthorizationRequired?Yes for high-costservicesNoYes for selectitemsExclusions and Limitations*Benefit managed by PHP Care Review team using HealthHelp ® , which has publishedcriteria listing exclusions and limitations.Benefit managed by PHP Care Review team using HealthHelp ® , which has publishedcriteria.• A. Special requirements for purchase of wheelchairs: Before billing for a customizedwheelchair, the provider who delivers the wheelchair and seating system to aneligible recipient must make a final evaluation to ensure that the wheelchair andseating system meets the medical, social, and environmental needs of the eligiblerecipient for whom it was authorized.• (1) The provider assumes responsibility for correcting defects or deficiencies inwheelchair and seating systems that make them unsatisfactory for use by theeligible recipient.• (2) The provider is responsible for consulting physical therapists, occupationaltherapists, special education instructors, teachers, parents or guardians, asnecessary, to ensure that the wheelchair meets the eligible recipient’s needs.• (3) Evaluations by a physical therapist or occupational therapist are required whenordering customized wheelchairs and seating systems. These therapists should befamiliar with the brands and categories of wheelchairs and appropriate seatingsystems and work with the eligible recipient and those consultants listed inParagraph (2) of Subsection B of 8.324.5.14 NMAC to assure that the selectedsystem matches physical seating needs. The physical or occupational therapistmay not be a wheelchair vendor or under the employment of a wheelchair vendoror wheelchair manufacturer.• (4) PHP does not pay for special modifications or replacement of customizedwheelchairs after the wheelchairs are furnished to the eligible recipient.• (5) When the equipment is delivered to the eligible recipient and the eligiblerecipient accepts the order, the provider submits the claim for reimbursement.• B. Special requirements for purchase of augmentative and alternativecommunication devices (AACDs):• (1) The purchase of AACDs requires prior authorization. In addition to beingprescribed by a physician, the communication device must also be recommendedby a speech-language pathologist, who has completed a systematic andcomprehensive evaluation. The speech pathologist may not be a vendor ofaugmentative communication systems nor have a financial relationship with avendor.• (2) A trial rental period of up to 60 calendar days is required for all electronicdevices to ensure that the chosen device is the most appropriate device to meetthe eligible recipient’s medical needs. At the end of the trial rental period, ifpurchase of the device is recommended, documentation of the eligible recipient’sability to use the communication device must be provided showing that the eligiblerecipient’s ability to use the device is improving and that the eligible recipient ismotivated to continue to use this device.• (3) PHP does not pay for supplies for AACDs, such as but not limited to paper,printer ribbons, and computer discs.• (4) Prior authorization is required for equipment repairs.• (5) A provider or medical supplier that routinely supplies an item to an eligiblerecipient must document that the order for additional supplies was requested bythe recipient or their personal representative and the provider or supplier mustconfirm that the eligible recipient does not have in excess of a 15-calendar-daysupply of the item before releasing the next supply order to the eligible recipient. Aprovider must keep documentation in their files available for audit that showcompliance with this requirement.F-42014 Practitioner and Provider Manual - Ver. 3