|
24.5.16.2 Prior Authorization and Required Documentation
Prior authorization is required for rental or purchase of an ACD system provided through Home Health Services. The prior authorization request should include all related accessories and/or supplies.
Before requesting prior authorization, 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. All signatures and dates must be current, original, unaltered, and handwritten. Computerized or stamped signatures will not be accepted. The date of the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form can be no more than three months before the service start date. Forms that are submitted more than three months before the start of service will result in an authorization rejection. A letter will be generated to the provider stating that the date of the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form is prior to the three-month limit. The completed, signed, and dated Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form must include the procedure codes and quantities for services requested and must be maintained by the DME provider and the prescribing physician in the client's medical record.
To facilitate a determination of medical necessity and avoid unnecessary denials when requesting prior authorization for an ACD system, the physician must provide correct and complete information supporting the medical necessity of the equipment and/or supplies requested, including:
• Diagnosis/condition causing impairment of communication.
•Accurate diagnostic information pertaining to any other medical diagnoses/conditions, to include the client's overall health status.
The following documentation must be submitted with the completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form:
•The physician familiar with the client will base his/her recommendation on the review of a formal written evaluation of cognitive and language abilities completed by a speech language pathologist (SLP). The prior authorization criteria must be addressed in this evaluation. The prescribing physician will review the professional evaluation/assessment and base the prescription on the recommendations.
•The formal written ACD system evaluation completed, signed, and dated by a speech-language pathologist (SLP) must include a minimum of all of the following information:
•Current communication impairment, including the type, severity, language skills, cognitive ability and anticipated course of the impairment.
•A description of the functional communication goals expected to be achieved and treatment options, including the ability of the requested ACD system, accessories and/or software to meet the projected communication needs of the client, and the length of time it is expected to meet their needs (must be anticipated to meet the client's needs for a minimum of 5 years).
•Anticipated changes, modifications or upgrades that will be needed to meet the future needs (up to 5 years) of the client, to include projected long and short term time frames.
•A treatment plan that includes a training schedule for the selected device and components addressing the needs of the client and caregiver to ensure appropriateness and optimal use of the prescribed device.
•Evaluation that the client possesses the cognitive, emotional and physical abilities to effectively use the selected device and any accessories to communicate, including cognitive, postural, mobility and sensory (visual and auditory) capabilities.
•Evaluation of the residential, vocational, educational and other settings/situations requiring communication (e.g., transportation), alternative ACD system evaluated, with a consideration of the advantages/disadvantages of the device considered as well as their appropriateness for the client.
•How the use of the ACD system will be implemented/integrated into various environments of use.
•Medical status/condition and medical diagnosis that is underlying the severe expressive speech disability leading to the need for an ACD system.
•An assessment of the client's daily communication needs and whether they could be met using other natural modes of communication.
•Other forms of treatment that have been considered and ruled out.
•The rationale for selection of a specific device and any accessories, including why the requested equipment is the most appropriate and cost effective for the particular client, and that the client's speech disability will benefit from the device ordered.
Note: The Texas Medicaid Program may request additional information to clarify or complete a request for an ACD system and accessories.
The SLP evaluation must be dated before the date on the physician's prescription (Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form).
An ACD system is expected to serve the client's needs for an extended period of time. Refer to "Replacement" for additional information.
|
