DME Task Force Submitted Questions 2018 · To clarify, I did visit with Great Plains the submitter...

DME Task Force Submitted Questions

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Due to the similarity of this year and past years questions and that Providers can and do email or phone the DME Administrator with their policy or service authorization questions the annual DME Task Force in person meeting is not as pertinent as in the past. Providers should not feel they need to wait a whole year or submit their questions as a group to receive guidance, so they can continue to provide their great services to North Dakota Medicaid members.

The Department has reviewed and responded to the 2018 DME Task Force questions in red below.

1. Can the C-pap CMN be eliminated? We have to submit the PSG and interpretation anyway to NDMA to a get a prior approved. The info on the CMN is the same information included in the physician record. It includes the PSG, interpretation, and a doctor signature. According to your requirements we have to have a signed RX and polysomnogram interpretation. The CMN is redundant.

The purpose of the CMN is to be a quick reference guide to policy criteria (a user aid) not a replacement for required medical documentation or a required prescription. The CMN is not an all-inclusive guide for NDMA coverage criteria. Therefore, is not a replacement for medical documentation. NDMA has been flexible in allowing physicians to utilize a CMN of their preference, which will at times require additional medical documentation to support medical necessity.

The Department has been receiving CMNs that have been modified by the providers, see example below.


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2. We are being informed by NDMA provider services that L8000 & L8030 are similar items, so the claim will only pay for the one item with the allowable per fee schedule.

Why would both HCPC codes be listed on the NDMA fee schedule with the allowable listed?

L8000 = BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTERGRATED BREAST PROTHESIS FORM, ANY SIZE, ANY FORM. Qty allowed = 4 per year

L8030 = BREAST PROSTHESIS, SILICONE OR EQUAL, WITHOUT INTEGRAL ADHESIVE Qty allowed = 1 per 2 years

The Department has not heard from the involved areas. An update will be posted on the Provider Update page when available.

3. We have been told that items dispensed while a patient is in a correctional facility (ex.

JRCC or ND St Pen) a service authorization is still required. When did this change and where is this listed in the provider manual?

The Department has heard from the Claims area an update will be posted on the Provider Update page.

4. It was discussed with Tammy that we will be able to submit WC accessories on two lines

when requesting a service authorization for the rental items, so they match primary's requirements. When will we be able to submit that way so crossover claims don't deny due to not matching the service auth? (ex. E0973, E0971, K0040, etc.)

To clarify, I did visit with Great Plains the submitter of this question before this question was submitted regarding their requests for rentals for the above codes. Data showed they were the only DME provider submitting a service auth. requesting more than 12 rental units for RT/LT. Other providers as utilizing Medicare’s guidance and submits these codes as purchase as are considered as routinely purchased for long term usage.

During our discussion Great Plains shared their claims submittal process for dual eligible members. They explained that they submit first to Medicare for the RT on one line and the LT on a second line. When Medicare claim crossover it will deny. To submit the claim to ND Medicaid they must submit the RT/LT as on one line to match the SA. This causes a lot of extra work for them as well as ND Medicaid. I shared that I was working with Conduent and Claims staff to hopefully to be able to remove some of the DME HCPC codes for Medicare Cross-overs to no longer require a service auth. thus not requiring DME providers to submit a claim at all.

Currently, I’m happy to share that it is looking very hopefully in the near future the Department will have a list of HCPC codes for Medicare Crossover that will no longer require a service auth. Once details are finalized the information will be shared with the providers via the Providers Update web page.


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5. Please clarify when you want face to face notes from a physician? Strictly for new

equipment? What about repairs or replacement parts?

NDMA does not require a Face to Face as this is a Medicare requirement. A Face to Face is a Medicare requirement. If the item was not originally approved, it requires the Dr. visit 60 days prior to the SA start date as needs documentation to support the item requested. If the item is needing repair or replaced on the originally approved equipment, then no Dr. visit is required. A prescription is along with notes stating why it is needing repair/replacement and the associated labor units if needed.

6. Face to face within 60 days. This continues to be an issue when there is a therapy

evaluation involved as typically it is after the physician face to face. The physician is co-signing the therapy evaluation – why can’t that be used as the face to face date for the notes?

This is allowed by most other insurances? With such a short time frame – it is causing additional doctor visits which would seem to cost your department more money. A member cannot self-refer to physical therapy. They must be seen by their physician who then determines what is the best option for them. If needed, the Dr. will order a PT evaluation. Once the PT evaluation is completed PT can send their recommendations back the order physician for their consideration. Member needs to see their physician as many are seeing physical therapy all year long and there may be other medical issues PT aren’t aware of or is not in their scope to address.

7. Could we get written clarification as to how the face to face encounter should be

documented? It is assumed it should be in a chart note, but it does not clearly say.

Some priors have been approved using only letters from physicians, while other prior requests have been denied stating “letters not acceptable”. We would like it in writing to clearly state what is required. Face to Face is a Medicare requirement so please contact them for clarification. A letter from the Dr. is considered a supporting document and it by itself is not a acceptable substitute for the required actual Dr. visit documentation 60 days prior to the SA start date. Dr. letters are not done at the time of the exam but is usually completed after the SA is denied so is considered a supporting document.


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The Dr. visit needs to have the notes showing the exam and any other notes supporting the item that is being requested. Please see the related policy as many have a list of criteria /questions that need to be addressed.

8. The Department has developed Quick Reference Links. If there is conflicting information between the Quick Link and the Policy which one takes precedence?

The Quick Reference link has a list of the current policies. If the item is not listed in the Quick Reference link list then refer to the DME Manual policy section for the information.

Providers may email their questions to Tammy Holm if they are seeing conflicting information so if needed the related policy can be revised.

9. Why are priors needed for secondary or tertiary claims when item has been approved by primary? (I know this has been asked over and over again, however I feel we need a better answer.)

The Department asked the group for clarification from the submitter of the question but has yet heard back.

As shared in Question #4, hopefully in the near future the Department will have a list of HCPC codes for Medicare Crossovers that will no longer require a service auth. Once details are finalized the information will be shared with the providers via the Providers Update web page.

10. Why is a polysomnogram required for an E0471 when the diagnosis is ALS? Patients with ALS will not have OSA or Central Sleep Apnea but will require a bipap with backup because of muscle weakness. In your policy it is not listed that a polysomnogram is required, but under the required documents it shows a polysomnogram is needed.

To require this of your clients is an unnecessary expense to your department and a hardship for this type of client to expect them to do this. There is no Medical justification for this test because it will not affect the patient outcome, diagnosis, or the need for the equipment.

The Respiratory Assist Device policy does not list the E0471 due to it is reviewed on a case by case bases and if needed the Medicare’s related coverage criteria is utilized. Dr. notes need to explain why they are ordering the E0471 and have related supporting information needed for the review.


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11. In addition to the above question, please clarify the coverage criteria for an E0471. The only reference to this product is stated in the C-pap Quick Link that it will not be covered for the diagnosis of OSA. E0471 is never mentioned in the Quick Link for Respiratory Assist Device (bipap).

Please see question #10 as previously addressed.

12. If a non-invasive ventilator is necessary because the client needs mouth piece ventilation and/or portability, why does the chart note have to state that a least costly option (bipap) has been tried and ruled out? A bipap is not portable and has to be plugged into the wall at all times. There is not a back-up battery in a bipap. The mouth-piece ventilation is also a mode not available on any bipap.

Federal regulations require that items covered by the Department be:

• Reasonable and necessary in amount, duration and scope to achieve their purpose. • The most economical and efficacious available to fulfill the basic medical need. There has been an increase in ventilator requests and each is reviewed based on our related policy and if needed Medicare’s policy is referenced. Medicare’s policy also clearly states the choice of an appropriate treatment plan, including the determination to use a ventilator vs. a bi-level PAP device, is made based upon the specifics of each individual member’s medical condition.

13. When a service auth is requested we will get it returned saying the chart note does not say

“bipap was considered and ruled out”. The two reasons above are why a bipap was ruled out. Why is this specific statement required?

Please see question #12 as previously addressed

14. Would it be possible to implement a standard form when we request approval for a RUL piece of equipment? Your department often requests all repair information plus the amount already spent on repairs. The many changes in requests by the reviewer often slows the process down. (Please see samples of a possible forms attached.)

The Department feels that it is the providers business to determine how they want to present the required information. There are several providers who have been using their own format for many years. If a provider is having issues they can send a copy of theirs to Tammy Holm for review and suggestions.


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15. Power wheelchairs have 4 casters and 2 drive wheels. Why are only 2 casters approved

per year?

Casters and drive wheels do not have the same HCPC code. Each HCPC code has its own allowable and that allowable does not affect other HCPC codes allowable. There was an issue with the system that was found and corrected Oct 2-2018. Providers can resubmit claims for payment if was incorrectly paid or denied.

16. Why are wheelchair batteries only allowed once every two years? Most batteries have a 6 to 12-month warranty per the manufacturer. If a battery needs replacing in month 15 who is responsible to pay for it?

Manual states providers can submit a service for early replacement with explanation. Please remember to add the replacement/repair modifier RB.

17. Why are priors needed for secondary or tertiary claims when item has been approved by primary? (I know this has been asked over and over again, however I feel we need a better answer.)

Duplicate question and previously addressed in question #9.

18. During a conversation with Tammy we discussed how we would like to submit WC accessories on two lines when requesting a service authorization for rental items. This way they will match the primary's requirements. At first we were told this was being tested and that it was working. Later, we were told we need to wait until further notice. We are wondering when we will we be able to submit that way so crossover claims don't deny due to not matching the service auth? (ex. E0973, E0971, K0040, etc.)

We are wondering where we are at in this process?

Duplicate question and previously addressed in question #4.

19. We have provided walkers and seats to patients residing in assisted living or basic care

facilities. These would be place of service 13 or 33. We were initially denied on the claims with the reason being that the SNF was responsible. After appealing several times, the E0143 Walker paid, but the E0156 Seat Attachment continually denies 190 - Payment included in SNF stay. Is this issue ever going to get resolved?

We explained that primary insurance wouldn't pay if the patient was in a SNF, but we are told NDMA’s file shows the patient is in a LTC facility and that item is that facility’s responsibility. We were told that basic care or assisted living is considered as a Long-Term Care facility, and that facility is responsible, just like a SNF. NDMA pays for the


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walker, but the seat attachment E0156 denies for SNF responsible. Why pay for the walker and not the seat? Both items are submitted with POS 13 or 33, (NOT 32 - SNF) Please refer to Claims question #4 as is a related issue.

CLAIMS QUESTIONS

1. Miscellaneous codes (ex. K0108, E1399, A9999) require the manufacture invoice when submitting a service authorization, to show the acquisition cost. Once the service authorization is approved, the claim gets submitted for processing. Why should we have to mail the claim attaching a copy of the manufacture's invoice again since we never had to do this before going live with MMIS? Shouldn't NDMA have that on file since it's required in order to get the service authorization approved? If the MMIS portal would be working for secondary claims, we would be able to attach the invoice to the claim, but until that is fixed, the claims have to be mailed with the invoice attached.

Since a service authorization is required for misc. codes and a copy of the manufacturer invoice is required to manually price (attached to the SA) Claims agree they would not require a copy of it to be sent with the claim. If for some reason, if Claims needed to look at the invoice they could view it through the authorization.

2. A4629 (TRACHEOSTOMY CARE KIT FOR ESTABLISHED TRACHEOSTOMY) allowable is 31 per month. When the claim is submitted with span dates, it denies due to NDMA not allowing span dates. If the claim is submitted for the date that it was dispensed, NDMA will only pay for 1 unit. What is the correct way to submit this HCPC to get it paid correctly for the allowed units?

This is related to the March heat ticket to update allowables which is still pending. An update will be posted on the Provider Update page when available.

3. According to the NDMA fee schedule, the allowable for A4520 (Incontinence garment) is allowed 180 per month. The allowable for A4351 and/or A4352 (catheters) are also 180 per month. If a patient receives both items in the same month, NDMA will only pay for 180 units after combining both items. These are two different items, but NDMA combines them and only pays up to 180 units unless there is a service authorization for dispensing over the allowable. NDMA has been aware of this issue and we're still waiting for a *FIX* for over a year. When will this *FIX* be in place so the provider can submit the claims, so it doesn't deny CO45 - Charge exceeds fee schedule/maximum allowable?

This MMIS issue was revised Oct. 2, 2018. So providers please resubmit related claims as needed.


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4. Claim submission for E0950 WC Tray has been denying for service authorization required. Back in 2015 when this item was dispensed, the fee schedule shows that a service authorization is NOT required. I have been told numerous times that this HCPC will be fixed so it doesn't deny for requiring a service authorization. Is this being looked into and is there an estimated time this is being corrected?

The Department is aware of this issue and how to correct the issue. Currently waiting to hear from the person who oversees MMIS revisions on guidance from her on what format is best to send the needed information be sent to her to update the system for nursing homes, ICF/IID, and Swing bed.

An update will be posted on the Provider Update page when available.

5. A service authorization is required for miscellaneous codes due to having to be manually prices. When the claim is being sent for processing, it usually pays at $0.00. We have been informed by provider services that the reason it pays at $0.00 is because the approved service authorization is missing either the approved amount OR the approved units. The suggestion is to contact the service authorization department asking to have the amounts entered. I'm informed by the SA department that it's a claims issue and nothing needs to be updated on the service authorization. How can we get these claims to process correct the first submission with the approved service authorization attached? Claims seem to be in SUSPENDED status for quite some time. I spoke with a representative from NDMA provider services asking if they could check on a claim that has been suspended since September 2017. I was informed that "Conduent is looking into this so there is nothing we can do at this time." That was 3 months ago, and to this day, the claim from 2016 is still in suspended status. Is there truly nothing that can be done to get these claims out of suspended status?

Revisions were previously made to existing approved SAs that had missing approved amounts. Notification letters were sent. Providers will need to resubmit claims for payment.

6. E0604 BREAST PUMP, HOSPITAL GRADE, ELECTRIC don't require a service authorization according to the NDMA fee schedule. How can we get claims paid successfully without deny for service authorization required?

Revision to MMIS was completed on 7-22-18 to allow the first month rental with no service auth. but if a second month rental is required a service auth. will be needed.


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Additional Information:

❖ The Department reminds providers to check Medicaid Provider’s Update web page for important updates regarding policy changes, billing and coding guidance etc. http://www.nd.gov/dhs/services/medicalserv/medicaid/provider-updates.html

❖ SERVICE AUTHORIZATION (Prior Authorization)

Under the North Dakota Medicaid program, certain covered services and equipment require prior approval to the provision of the service(s) as a condition of reimbursement. A service authorization submitted by the DME Provider and its attached required supporting documents is reviewed solely for medical necessity, appropriateness of items requested, and location of service, if most cost-effective, and if in compliance with the Department’s DME policy coverage criteria, prior to delivery of service.

Prior approval from the Department only pertains to medical necessity of the items

requested on the service authorization. It does not guarantee payment, member eligibility or prevent later recoupment of paid claims, during an audit, if all billing and

document/documentation requirements are not fulfilled.

❖ The Claims department reminds providers when submitting a claim for hearing aids, batteries, incontinence, etc. that do not require a claim to be submitted to Medicare or Medicare replacement/supplements plans it is not required to be entered in the 9d section of the HCFA form (see screenshot below). If any insurance is listed on the HCFA form section 9d then the EOB is required and without it the claim will be denied.

http://www.nd.gov/dhs/services/medicalserv/medicaid/provider-updates.html


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❖ The Claims department reminds providers when submitting claims for DME items service auth. required or not requires the appropriate modifiers to be submitted or the claim will be denied. For example, NU for purchase, RR for rentals, RB for repairs/replacement, LT for left and RT for right.

❖ As always please feel free to contact Tammy Holm anytime by email with policy questions or questions that the Call Center was not able assist when they occur via email at

[email protected].

❖ Future Claims denials/questions needing assistance process:

1. Contacting the Call Center or emailing [email protected].

2. If you still have questions contact the Claims Supervisor Cheryl Nelson at [email protected]. Please include the Call Center call reference (CR) number that is given when calling in or forward the MMIS email to prevent delays in providing assistance.

Program Integrity

The Department is now working with the Unified Program Integrity Contractors (UPIC) and providers may possibly see audits from them in the future. The UPIC vendor for ND is Qlarant (pronounced Clarant).

The following questions were submitted after the question deadline for review.

Question #1

mailto:[email protected]




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The DME Manual on page 9 General Coverage Principles state all health care services received by

Medicaid clients, services rendered by these providers must also meet the general requirements listed in the Provider Requirements chapter of the General Information For Providers manual. North Dakota Medicaid considers Medicare, Region D DMERC medical review policies as the minimum DMEOPS industry standard. DMEOPS providers are required to follow specific North Dakota Medicaid policy or applicable Medicare policy when North Dakota Medicaid policy does not exist.

The DME Manual Powered Wheelchair policy on page 75 states documentation must be included that a home assessment has been completed. This required information is needed to ensure that the member can adequately maneuver the requested device in the physical layout, doorway width, doorway thresholds, and surfaces in their home.

Question #2

The DME Manual repair section on page 12 states the Department will consider repair versus replacement if the repairs do not exceed 75% of replacement. To make the determination the provider is required to submit an itemized breakdown of the cost of replacement/purchase vs repair/modification(s) to existing w/c cost is needed using ND Medicaid rates to assist the Department in making this determination. Without the comparison the service auth. request will be denied. Accumulative is not all the past history of repairs as members are not required to continue to use the same provider the equipment was originally obtained through. Some members are new to our State or have moved to a different area that provider does not cover so there is no past repair or modification history. The Department takes in to consideration if available, the history of repairs to see if there is a pattern of repairs to see if there is possible abuse/misuse or to see if requested accessories where initially approved with the equipment. The Department agrees that some powered wheelchairs and other equipment can be costly, but that is why the Department needs to review the comparison to repair, to the cost of replacing with a new one. If the cost is not 75% or more of new, then it will be repaired. Many times, the Department was just requested and approved a new tilt or motors and batteries 3 months before and then receive a request for a new chair based on the chair is 7 years old and now needs a new cushion, tires and arm rests. The cost to repair is 35% so this chair has new motor, batteries, arm rests, tires and cushions so is pretty much new except for maybe bearings and joystick.

http://www.nd.gov/humanservices/services/medicalserv/medicaid/docs/gen-info-providers-april2006.pdf


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ND Medicaid follows our documentation criteria to ensure compliance with Medicaid policies regardless of Primary or Secondary payer source. Please note, should the Department be audited, we need to have documentation to support our decision, regardless if ND Medicaid was the primary or secondary payer source. There has been an increased emphasis on program integrity nationally, and by us asking for the documentation, it protects not only the Department, but the provider as well. ND Medicaid reviews a 100% of all service authorization requests. Therefore, provider’s cooperation is greatly appreciated in providing the additional documentation needed for the adjudication process to be completed in an efficient manner that meets our policy criteria.

The replacement of wheelchair may be covered for other reasons other than when the cost of the repair is 75% of the replacement cost. For example; the member has other extenuating medical circumstances occur which requires special consideration; or the current wheelchair no longer can meet the member’s needs due to a change in medical condition.

Question # 3


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Above is the Departments response to providers at the 2013 DME Task Force meeting. To date the Department has not received the collected data and the SA review process continues to be conducted based on policy coverage criteria. The Exception Request section of the DME Manual on page 21 states “items denied as “non-covered”, because required criteria has not been met, may be requested “as an exception”. The E1007, E1010, and the E1012 are not listed on the fee schedule or listed on the wheelchair policy either and would not be considered “as an exception” they are not covered by ND Medicaid and have no set coverage criteria. If submitted, they would be denied as non-covered.

DME Task Force Submitted Questions 2018 · To clarify, I did visit with Great Plains the submitter...

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Transcript of DME Task Force Submitted Questions 2018 · To clarify, I did visit with Great Plains the submitter...