TMPPM 2008 > Texas Medicaid Services > Texas Medicaid (Title XIX) Home Health Services > Benefits

24.5.15 Durable Medical Equipment (DME) and Supplies

The Texas Medicaid Program defines DME as:

Medical equipment or appliances that are manufactured to withstand repeated use, ordered by a physician for use in the home, and required to correct or ameliorate a client's disability, condition, or illness.

Since there is no single authority, such as a federal agency, that confers the official status of "DME" on any device or product, HHSC retains the right to make such determinations with regard to DME benefits of the Texas Medicaid Program. DME benefits of the Texas Medicaid Program must have either a well-established history of efficacy or, in the case of novel or unique equipment, valid, peer-reviewed evidence that the equipment corrects or ameliorates a covered medical condition or functional disability.

Requested DME may be a benefit when it meets the Medicaid definition of DME.

The majority of DME and expendable supplies are covered Home Health Services.

If a service cannot be provided for a client younger than 21 years of age through Home Health Services, these services may be covered through THSteps-CCP if they are determined to be medically necessary.

To be reimbursed as a home health benefit:

•The client must be eligible for home health benefits.

•The criteria listed for the requested equipment must be met.

•The equipment requested must be medically necessary, and federal financial participation must be available.

•The client's health status would be compromised without the requested equipment.

•The requested equipment or supplies must be safe for use in the home.

•The client must be seen by a physician within one year of the DOS.

A completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form prescribing the DME and/or supplies must be signed and dated by a physician familiar with the client before requesting prior authorization for all DME equipment and supplies. All signatures must be current, unaltered, original, and handwritten. Computerized or stamped signatures will not be accepted. The completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form must include the procedure codes and quantities for services requested. The completed, signed, and dated form must be maintained by the DME provider and the prescribing physician in the client's medical record. The completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form with the original signature must be maintained by the prescribing physician.

Prior authorization is required for most DME and services provided through Home Health Services. These services include accessories, modifications, adjustments, and repairs for the equipment.

The date last seen by the physician must be within the past 12 months unless a physician waiver is obtained. The physician's signature on the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form is only valid for 90 days before the initiation of services.

Obtain authorization within three business days of providing the service by calling TMHP Home Health Services Authorization Department or faxing the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form. A determination will be made as to whether the equipment will be rented, purchased, repaired, modified, or denied based on the client's medical necessity.

To facilitate a determination of medical necessity and avoid unnecessary denials when requesting prior authorization, the physician must provide correct and complete information supporting the medical necessity of the equipment and/or supplies requested, including:

•Accurate diagnostic information pertaining to the underlying diagnosis/condition as well as any other medical diagnoses/conditions, to include the client's overall health status.

•Diagnosis/condition causing the impairment resulting in a need for the equipment and/or supplies requested.

The provider must have the client sign the DME Certification and Receipt Form on page B-35 for all purchased DME for Medicaid clients before submitting a claim for payment. The client's signature means the DME is the property of the client. The certification form also requires the name of the item and the date the client received the DME. The DME supplier should retain this form, not submit it with the claim.

The provider must keep all Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Forms and Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Forms on file. Providers must retain delivery slips or invoices and the signed and dated DME Certification and Receipt Form documenting the item and date of delivery for all DME provided to a client and must disclose them to HHSC or its designee on request.

•The DME must be used for medical or therapeutic purposes, and supplied through an enrolled DMEH provider in compliance with the client's POC.

•These records and claims must be retained for a minimum of five years from the DOS or until audit questions, appeals, hearings, investigations, or court cases are resolved. Use of these services is subject to retrospective review.

Note: All purchased equipment must be new upon delivery to client. Used equipment may be utilized for lease, but when purchased, must be replaced with new equipment.

HHSC/TMHP reserves the right to request the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form and/or Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form at any time.

DME must meet the following requirements to qualify for reimbursement under Home Health Services:

•The client received the equipment as prescribed by the physician.

•The equipment has been properly fitted to the client and/or meets the client's needs.

•The client, the parent or guardian of the client, and/or the primary caregiver of the client, has received training and instruction regarding the equipment's proper use and maintenance.

DME must:

•Be medically necessary due to illness or injury or to improve the functioning of a body part, as documented by the physician in the client's POC or the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form.

•Be prior authorized by the TMHP Home Health Services Prior Authorization Department for rental or purchase of supplies for most equipment. Some equipment does not require prior authorization. Prior authorization for equipment rental can be issued for up to six months based on diagnosis and medical necessity. If an extension is needed, requests can be made up to 60 days before the start of the new authorization period with a new Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form.

•Meet the client's existing medical and treatment needs.

•Be considered safe for use in the home.

•Be provided through an enrolled DMEH provider/supplier.

Note: THSteps-eligible clients who qualify for medically necessary services beyond the limits of this home health benefit will receive those services through THSteps-CCP.

DME that has been delivered to the client's home and then found to be inappropriate for the client's condition will not be eligible for an upgrade within the first six months following purchase unless there had been a significant change in the client's condition, as documented by the physician familiar with the client. All adjustments and modifications within the first six months after delivery are considered part of the purchase price.

All DME purchased for a client becomes the Medicaid client's property upon receipt of the item. This property includes equipment delivered which will not be prior authorized or reimbursed in the following instances:

•Equipment delivered to the client before the physician signature date on the POC or Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form or Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.

•Equipment delivered more than three business days before obtaining prior authorization from the TMHP Home Health Services Prior Authorization Department and meets the criteria for purchase.

Additional criteria:

•The TMHP Home Health Services Prior Authorization Department will make the final determination whether DME will be rented, purchased, or repaired based on the client's duration and use needs.

•Periodic rental payments are made only for the lesser of either the period of time the equipment is medically necessary, or when the total monthly rental payments equal the reasonable purchase cost for the equipment.

•Purchase is justified when the estimated duration of need multiplied by the rental payments would exceed the reasonable purchase cost of the equipment or it is otherwise more practical to purchase the equipment.

•DME repair will be considered based on the age of the item and cost to repair it.

•A request for repair of DME must include a statement or medical information from the attending physician substantiating that the medical appliance or equipment continues to serve a specific medical purpose and an itemized estimated cost list from the vendor or DME provider of the repairs. Rental equipment may be provided to replace purchased medical equipment for the period of time it will take to make necessary repairs to purchased medical equipment.

•If a DME/medical supply provider is unable to deliver an authorized piece of equipment or supply, the provider should allow the client the option of obtaining the equipment or supplies from another provider.

Items and/or services addressed are reimbursed at a maximum fee determined by HHSC. If an item is manually priced, the MSRP must be submitted for consideration of rental or purchase with the appropriate procedure codes. Purchases and rentals are reimbursed at the MSRP minus a discount as determined by HHSC.

DME is anticipated to last a minimum of five years and may be considered for replacement when five years have passed and the equipment is no longer functional and repairable. The DME may then be considered for prior authorization. Replacement of equipment will be considered when loss or irreparable damage has occurred. A copy of the police or fire report when appropriate, with the measures to be taken to prevent reoccurrence, must be submitted.

Replacement, adjustments, modifications, or repairs will not be authorized in situations where the equipment has been abused or neglected by the client, the client's family, or the caregiver. A referral to the DSHS Medical Case Management Department will be made by TMHP Home Health Services Prior Authorization Department (or CCP Department, where appropriate) for clients younger than 21 years of age. Providers will be notified that the state will be monitoring this client's services.

Prior authorization is required for replacement. Replacement will be considered in at least one of the following situations:

•After the maximum limitation time has elapsed and the DME is no longer functional and/or repairable.

•When irreparable damage has occurred.

Documentation, which must accompany a request, includes a statement from the prescribing physician, which includes:

•A copy of the fire or police report.

•The cause of the loss or damage and what measures will be taken to prevent reoccurrence.

Those who supply DME equipment and supplies to Medicaid Managed Care clients must obtain a prior authorization form. Services and supplies for STAR+PLUS Medicaid Qualified Medicare Beneficiary (MQMB) clients should be billed to Medicare first. If denied, submit them to TMHP to consider. The STAR+PLUS health plan is not responsible for these services.

Cancelling an authorization

The client has the right to choose his DME/medical supply provider and change providers. If the client changes providers, TMHP must receive a change of provider letter with a new Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form. The client must sign and date the letter, which must include the name of the previous provider and the effective date for the change. The client is responsible for notifying the original provider of the change and the effective date. Prior authorization for the new provider can only be issued up to three business days before the date TMHP receives the change of provider letter and the new Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form.

Repairs

Repairs will not be authorized in situations where the equipment has been abused or neglected by the client, client's family, or caregiver.

Routine maintenance of rental equipment is the provider's responsibility.

For clients requiring wheelchair repairs only, the date last seen by physician does not need to be filled in on the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form.

Benefits of the Home Health Services Program such as medical equipment (rental, purchase, or repairs) includes, but is not limited to:

•Manual or powered wheelchairs: noncustomized, including medically justified seating, supports, and equipment, or customized, specifically tailored or individualized, wheelchairs, including appropriate medically justified seating, supports, and equipment not to exceed an amount specified by HHSC.

Example: If a wheelchair is requested, the provider should define additional items needed, such as foot rests or crutch holders, removable arms, or special attachments.

•Canes, crutches, walkers, and trapeze bars.

•Bed pans, urinals, bedside commode chairs, elevated commode seats, bath chairs/benches/seats, and bath tub rails that are not wall-mounted.

•Electric and nonelectric hospital beds, mattresses, and bed-side rails.

•Air flotation or air pressure mattresses and cushions.

•Reasonable and appropriate appliances for measuring blood pressure and blood glucose suitable to the client's medical situation to include replacement parts and supplies.

•Freestanding lifts for assisting the client to ambulate within their residence or to transfer the client from one piece of equipment to another.

•Pumps for feeding tubes and IV administration.

•Respiratory or oxygen-related equipment.

Payment may be authorized for repair of purchased DME. Maintenance of rental equipment (including repairs) is the supplier's responsibility. The toll-free number for the TMHP Home Health Services Prior Authorization Department is 1-800-925-8957. Requests for repairs must include the cost estimate, reasons for repairs, age of equipment, and serial number.

Refer to: "Physician Supervision-Plan of Care" .

"DME Certification and Receipt Form".

"Home Health Services Plan of Care (POC)".

"Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Instructions (2 Pages)" and

"Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form".

"Procedure Codes That Do Not Require Prior Authorization" for equipment that does not require prior authorization.

"Provider Enrollment" .