Chapter 14 Durable Medical Equipment (DME)

Durable Medical Equipment (DME)Deleted:motorized/powerAdded: EPSDT referredspecializedDeleted: must have atleast…withNRRTS/RESNA.Added: must beregistered…of NorthAmerica (RESNA).Deleted: have at leastone…of North America(RESNA).Deleted: After October1, 2004…mayparticipate.Requests for EPSDT-referred specialized wheelchair systemsRequests for EPSDT-referred specialized wheelchair systems must be sent hard copy.Medicaid uses Medicare-based allowables for EPSDT-referred wheelchair systems. Ifno Medicare price is available, reimbursement rates established by Medicaid forEPSDT-referred wheelchair systems are based on a discount from ManufacturersSuggested Retail Price (MSRP) instead of a "cost-plus" basis.Providers are required to submit available MSRPs from three manufacturers forwheelchair systems (excluding seating system and add-on products) appropriate forthe individual's medical needs.Requests submitted with fewer than three prices from different manufacturers mustcontain documentation supporting the appropriateness and reasonableness ofrequested equipment for a follow-up review by Medicaid professional staff. Providermust document non-availability of required MSRPs to justify not sending in three prices.The established rate will be based on the MSRP minus the following discounts:• Manual Wheelchair Systems - 20% discount from MSRP• Power Wheelchair Systems - 15% discount from MSRP• Ancillary (add-on) products - 20% discount from MSRPSuppliers requesting approvals for medical items must provide Medicaid with anexpected date of delivery.For medical items approved based on medical necessity, Medicaid will indicate the timeframe allowed for providers to dispense equipment on the approval letter.When a provider is unable to dispense equipment within the time frame specified onthe approval letter, an extension may be requested with written justification as to thespecific reason(s) why the equipment cannot be supplied in a timely manner. Allrequests for extensions must be submitted to Medicaid prior to the expiration dateindicated on the approval letter. Medicaid will cancel approvals for medical items thatare not dispensed in a timely manner when there is no justifiable reason for delay.The Medicaid screening provider and recipient will be notified when an approvedrequest for equipment is canceled due to provider noncompliance and the recipient willbe referred to other Medicaid providers to obtain medical items.A supplier providing EPSDT referred specialized wheelchair systems to recipients mustbe registered with the National Registry of Rehab Technology Suppliers (NRRTS) orhave certification from Rehabilitation Engineering and Assistive Technology Society ofNorth America (RESNA).14.4 Patient 1st ReferralsWhen filing claims for recipients enrolled in the Patient 1 st program, refer to Chapter 39,Patient 1 st Billing Manual to determine whether your services require a referral from thePrimary Medical Provider (PMP).14.5 Cost-Sharing (Copayment)Medicaid recipients are required to pay and suppliers are required to collect thedesignated copay amount for the rental/purchase of services, supplies, appliances, andequipment, including crossovers. The copayment does not apply to services provided14-32 April 2005