Manual for Durable Medical Equipment, Prosthetics ...

1 Manual for Durable Medical equipment , Orthotics, Prosthetics &. supplies (DMEOPS). Published by: Medical Services north dakota Department of Human Services 600 E Boulevard Ave, Dept 325. Bismarck, ND 58505. March 2013. FORWARD. PURPOSE. This handbook has been prepared for the information and guidance of Durable Medical equipment and Medical supply providers who provide items or services to participants in the Department's Medical Programs. Contained in this handbook are both policy and procedures for Durable Medical equipment and Medical supply items and services. This handbook provides information on which items require prior approval and how to obtain prior approval.

2 Providers will be held responsible for compliance with all policy and procedures contained herein. TABLE OF CONTENTS. KEY CONTACTS .. 1. STATEMENT OF INTENTION .. 2. PURPOSE OF THE MEDICAID PROGRAM .. 2. DEPARTMENT OF HUMAN SERVICES, Medical SERVICES DIVISION .. 2. INTRODUCTION .. 4. Manual ORGANIZATION .. 4. RESPONSIBILITY FOR 4. PROVIDER ENROLLMENT .. 4. CHANGES IN 6. CHANGE IN OWNERSHIP .. 6. TERMINATING MEDICAID ENROLLMENT .. 6. PROVIDER REQUIREMENTS .. 6. PAYMENT FOR SERVICES .. 7. MEDICAID PAYMENT IS PAYMENT IN FULL .. 7. UTILIZATION MANAGEMENT .. 8. CLAIMS REVIEW .. 8. GETTING QUESTIONS ANSWERED .. 8. GENERAL COVERAGE PRINCIPLES .. 9. SERVICES FOR CHILDREN.

3 9. PROVISION OF SERVICES .. 9. PROVIDER DOCUMENTATION ..10. CERTIFICATE OF Medical NECESSITY ..11. RENTAL/PURCHASE ..11. REPAIRS ..12. NON COVERED equipment AND supplies ..13. PRIOR AUTHORIZATION ..14. PRIOR AUTHORIZATION FORM COMPLETION GUIDE ..16. PRIOR AUTHORIZATION ADJUSTMENT/COMPLETION QUANTITY LIMITATIONS: ..20. PRESCRIPTION REQUIREMENTS: ..20. EXCEPTION REQUESTS ..21. CODING ..21. COORDINATION OF BENEFITS .. 22. WHEN CLIENTS HAVE OTHER COVERAGE ..22. IDENTIFYING AND VERIFYING ADDITIONAL COVERAGE ..22. PRIVATE HEALTH CARE PLANS AND THIRD PARTY PAYERS ..22. RECIPIENT COOPERATION WITH TPL BILLING ..23. INSTRUCTIONS TO CHECKING CLIENT ELIGIBILTY .. 24. VERIFY OPERATIONAL STEPS.

4 24. BILLING 25. CLAIM FORMS ..25. ELECTRONIC CLAIMS ..25. PAPER USING THE MEDICAID FEE SCHEDULE ..27. MISCELLANEOUS/NOT OTHERWISE SPECIFIED HCPCS CODES ..27. CLAIM INQUIRIES ..27. THE MOST COMMON BILLING ERRORS AND HOW TO AVOID THIRD PARTY PAYMENT BILLING INSTRUCTIONS ..28. REMITTANCE ADVICE REBILLING AND ADJUSTMENTS ..31. WHAT IS RECIPIENT LIABILITY ..31. TAKING RECIPIENT LIABILITY (RL) AT THE time OF WHAT IS THE FUNCTION OF 32. DESK AUDITS ..32. KEY POINTS ..32. BILLING TIPS ..32. DEFINITIONS AND ACRONYMS .. 34. APPENDIX A PROVIDER ENROLLMENT FORMS .. 38. PROFESSIONAL ..38. OUT-OF-STATE PROVIDERS ..38. APPENDIX B NON COVERED-NO EXCEPTION 40. APPENDIX C GUIDELINES.

5 44. APNEA MONITOR ..44. ANKLE-FOOT/KNEE-ANKLE-FOOT ORTHOSIS ..44. AFO AND KAFO, CUSTOM: ..45. BATH/SHOWER CHAIR OR TUB STOOL/BENCH ..46. BILIRUBIN BLOOD GLUCOSE MONITORS: ..46. BREAST PUMP ..47. CANE/CRUTCHES ..48. CERVICAL TRACTION HOME DEVICES ..48. CHEST WALL OSCILLATING DEVICE (AIRWAY VEST SYSTEM) ..49. COLD THERAPY ..49. COMMODES/CHAIRS ..49. CONTINUOUS PASSIVE MOTION EXERCISE (CPM) ..50. CONTINUOUS POSITIVE AIRWAY DEVICE (CPAP) ..50. CRANIAL REMOLDING ENCLOSED BED ..50. ENTERAL NUTRITION ..50. EXERCISE equipment ..52. EXTERNAL BREAST PROSTHESIS ..52. EXTERNAL INSULIN INFUSION PUMP ..52. EXTERNAL INFUSION PUMP ..54. EYE PROSTHESIS ..55. FACIAL FIRST AID supplies .

6 56. HEARING AIDS: ..56. HOSPITAL INCONTINENCE GARMENTS (ADULT & YOUTH) ..59. NEBULIZERS: ..59. OSTEOGENIC BONE STIMULATOR ..60. OSTOMY supplies : ..61. OXYGEN PARENTERAL NUTRITION ..62. PATIENT LIFTS ..63. PNEUMATIC PRESSURE DEVICES ..63. POWER OPERATED VEHICLE ..63. PRESSURE REDUCING SUPPORT prosthetic DEVICES ..64. PULSE OXIMETER/ supplies ..64. RESPIRATORY ASSIST DEVICES (BIPAP)..65. SADD LIGHTS ..66. SEAT LIFT SPEECH GENERATING DEVICE ..66. STANDING FRAME ..67. SUCTION PUMPS ..67. SURGICAL DRESSINGS ..68. THERAPEUTIC SHOES/ INSERTS ..70. TLSO/LSO ..70. TRACH CARE KITS ..71. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATORS (TENS) ..71. UROLOGICAL supplies : ..71.

7 WALKERS/GAIT TRAINERS ..72. WHEELCHAIR -- Manual ..72. WHEELCHAIR -- OPTIONS/ACCESSORIES ..73. WHEELCHAIR -- POWERED BASE ..75. WHEELCHAIR -- SEATING ..75. WOUND THERAPY DEVICES ..76. APPENDIX D DME IN FACILITIES .. 77. APPENDIX E PRIOR APPROVAL ALWAYS REQUIRED .. 81. APPENDIX F LIST OF MODIFIERS .. 82. KEY CONTACTS. THIRD PARTY LIABILITY PROVIDER RELATIONS. For questions about private For questions about insurance, Medicare, or other recipient liability payments, third-party liability: denials or general claims questions: (800) 755-2604. (701) 328-3507 (800) 755-2604. (701) 328-4030. Send written inquiries to: PRIOR AUTHORIZATION (PA). Third Party Liability Unit Medical Services Mail or fax all requests for ND Dept.

8 Of Human Services prior authorization to: 600 E Boulevard Ave-Dept 325. Bismarck ND 58505-0250 Medical Services Administrator Quality Care/Disability ELECTRONIC CLAIMS ND Dept. of Human Services 600 E Boulevard Ave-Dept 325. For questions regarding Bismarck ND 58505-0250. electronic claims submission: Fax: 1-(701) 328-0370. (800) 755-2604 PROVIDER INFORMATION. (701) 328-2325. Fax: 1-(701) 328-1544 ces/medicalserv/medicaid/p PAPER CLAIMS. Send paper claims to: Claims Processing Medical Services ND Dept of Human Services 600 E Boulevard Ave Dept 325. Bismarck ND 58505-0250. 1. STATEMENT OF INTENTION. Supersedes: north dakota Medicaid DMEOPS ( Durable Medical equipment , Orthotics & Prosthetics , and Medical supplies ) Manual , March 2003, and all changes that have occurred in memorandums.

9 References: Title XIX, Social Security Act; United States Code (USC) 1396-1396v, Subchapter XIX, Chapter 7, Title 42; Code of Federal Regulations (CFR), Chapter IV, Title 42, Subtitle A, Title 45; Administrative Rules of north dakota Title , Chapter 02. Updated: June 2006. Codes, References, Etc. Mentioned in This Manual are Excerpts From: American Medical Association Current Procedural Terminology (CPT) 2006. CMS Healthcare Common Procedure Coding System (HCPCS). 2006. References are available at local bookstores or PURPOSE OF THE MEDICAID PROGRAM. The north dakota Legislature enacted legislation, which permits direct payment to providers for medically necessary services provided to Medical assistance recipients.

10 This legislation is contained in Title 75 Article 02, Chapter 02 of the north dakota Administrative Code. This law conforms to Title XIX of the Federal Social Security Act, Section 1901, to enable each state to furnish: Medical assistance on behalf of families with dependent children, aged, blind or disabled individuals, whose income and resources are insufficient to meet the cost of necessary Medical services; and Rehabilitation and other services to help such families and individuals to attain or retain the capability of independence or self-care. This program is referred to as Medicaid, or Title XIX. Funding is provided by a combination of state and federal dollars.