Presented byDisability Rights California

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www.disabilityrightsca.org

Medi-Cal puts assistive technology in a number of categories. For example it may be called: medical supplies, durable medical equipment, or a prosthetic device

State law defines medically necessary as: services, medicines, supplies and devices… necessary to protect life, to prevent a significant illness or disability, or to alleviate severe pain. California Welfare & Institutions Code §§ 14059.5, 14133.3

The definition of “medical necessity” for children is broader than the definition for the regular Medi-Cal program.

It includes “necessary health care, diagnostic services, treatment, and other measures ... to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the state plan.” 42 U.S.C. § 1396(r)(5) and 22 C.C.R. § 51184(b).

A written prescription of a licensed practitioner within the scope of his or her practice as established in California law is required for authorization of purchase, rental, repair or maintenance of DME.

For almost all technology, a doctor or medical provider must submit a Treatment Authorization Request (TAR) form that describes why a person needs the requested services, medicine or device. The provider must provide complete justification (i.e. show medical necessity) for the requested device otherwise, it is likely that the device may not be approved.

Provider manual contains specific documentation required for certain equipment.

http://files.medi-cal.ca.gov/pubsdoco/Manuals_menu.asp

In our experience, a well written medical necessity letter which explains the connection between the DME and components requested and the recipient’s disability is very important.

It is also important to have the medical professional explain how the DME is the least costly alternative that meets the recipient’s medical needs.

Additional advocacy tips can be found in the Winter 2006 AT Advocate Newsletter article: “PREPARING LETTERS OF MEDICAL JUSTIFICATION: Key Components That Will Support the Need for Durable Medical Equipment Through Medicaid and Other Third Party Insurers” which can be found at: http://www.nls.org/av/winter06.pdf.

Treatment Authorization Requests (TARs) must be submitted to the appropriate Medi-Cal field office. If a TAR is received in the wrong field office, it will be routed to the correct office.

TAR for DME is submitted by the DME provider/vendor.

The Medi-Cal consultant in the field office approves, modifies, defers (for more information) or denies each TAR, depending on Department of Health Care Services (DHCS) policy. After review, an Adjudication Response (AR) is generated and mailed to the address associated with the provider’s Medi-Cal ID or faxed to the submitting provider.

If the Medi-Cal program does not act on a TAR within 30 days of receiving it, the TAR is deemed to be approved by operation of law.

Calendar

A good DME provider makes a difference. Do some research

Ask questions (will you consult with me for free; how long in business; how will you make sure that the wheelchair fits in my home; what happens if I have problems with my wheelchair after I receive it…)

Rendering providers of DME shall ensure that all devices and equipment are appropriate to meet the recipient’s medical needs. If a piece of equipment or a device, when in actual use, fails to meet the recipient’s needs, and the recipient’s medical condition has not significantly changed since the device/equipment was dispensed, the rendering provider shall adjust or modify the equipment, as necessary, to meet the recipient’s needs. The rendering provider, at no cost to the Medi-Cal program, shall replace any equipment or device that cannot be adjusted or modified. CCR, Title 22, Section 51321 (i)

Medi-Cal Fraud Hotline: 1-800-822-6222 Get help to understand your rights:

Another vendor Look for help (DRC; ILC) California Lemon Laws

Appeal Rights

You should receive a Notice of Action that explains why Medi-Cal is denying request;

You have a right to file an appeal within 90 days; If you don’t get a notice, you still have a right to

appeal;

There are two ways to file for a hearing:

1st option: You may complete the "Request for State Hearing" on the back of the Notice of Action. Please provide all requested information.

Then you may submit your request one of these ways: ▪ (1) To the county welfare department at the address

shown on the Notice of Action.▪ (2) To the California Department of Social Services, State

Hearings Division, P.O. Box 944243, Mail Station 19-37, Sacramento, California 94244-2430. ▪ (3) To the State Hearings Division at fax number (916)

229-4110.

2nd Option: You may make a toll-free call to request a State Hearing at the following number. If you decide to make a request by telephone, you need to be aware that the telephone lines are very busy.

California Department of Social Services Public Inquiry and Response Phone 1-800-952-5253 (Voice) 1-800-952-8349 (TDD)

NOTE The State Hearings Division cannot accept requests for a state hearing via e-mail.

Advocacy tip: Keep a copy of all documents you submit. Also, write down the names of anyone you speak to at the State Hearings Division regarding your request for a state hearing.

See, the CDSS State Hearings Division website for more information:http://www.dss.cahwnet.gov/shd/PG1107.htm

After you file your appeal, you will receive a letter acknowledging your hearing request.

You will eventually receive a date and time for a hearing with an administrative law judge;

Medi-Cal is represented by a county representative (non-attorney).

As soon as you get an acknowledgement of your fair hearing request with the hearing number, write to the Medi-Cal field office that denied the TAR. The address is on the TAR denial notice. Ask to review the file and the authority Medi-Cal is relying upon including statutes, regulations and any provisions of the DHS Manual of Criteria and any policy letters.

Seek a good provider; Get help as soon as you know that Medi-Cal

said “no” to your request; Don’t miss your appeal deadline. DRC publication: “Accessing Assistive

Technology” in the publications and resources section of website: www.disabilityrightsca.org.

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Regional Offices Sacramento Bay Area Fresno Los Angeles San Diego

Toll Free: (800) 776-5746TTY: (800) 781-4546

AT Network Staff Kim Cantrell (Director of Programs) kim@cfilc.org Allan Friedman (Technologies Manager)

allan@cfilc.org LaCandice McCray (Outreach & Training Advocate)

lacandice@cfilc.org Mazuri Colley (Information & Assistance Advocate)

mazuri@cfilc.orgCFILC phone: 916-325-1690AT Network I&R Line: 800-390-2699