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2012 Texas Medicaid Provider Procedures Manual

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook : 2. Texas Medicaid (Title XIX) Home Health Services : 2.2 Services, Benefits, Limitations and Prior Authorization : 2.2.14 Mobility Aids : 2.2.14.24 Accessories, Modifications, Adjustments and Repairs

2.2.14.24
Accessories, modifications, adjustments, and repairs are benefits of Texas Medicaid as outlined below.
All modifications and adjustments to a wheeled mobility system, as well as the associated services by the QRP for the seating assessment and fitting, within the first six months after delivery are considered part of the purchase price.
Mobility aids that have been purchased are anticipated to last a minimum of five years.
A major modification to a wheeled mobility system requires the completion of a new seating assessment by a qualified practitioner (physician, occupational therapist, or physical therapist), with the participation of a QRP.
Prior authorization for equipment replacement is considered within five years of equipment purchase when one of the following occurs:
A wheeled mobility system that has been fitted and delivered to the client's home by a QRP and then found to be inappropriate for the client's condition will not be eligible for an upgrade, replacement, or major modification within the first six months following purchase unless there has been a significant change in the client's condition. The significant change in the client's condition must be documented by a physician familiar with the client.
2.2.14.24.1 Prior Authorization
Modifications
Modifications to custom equipment after the first six months from fitting and delivery may be prior authorized when a change occurs in the client's needs, capabilities, or physical/mental status that cannot be anticipated.
Modifications are the replacement of components due to changes in the client's condition, not replacement due to the component no longer functioning as designed. All modifications within the first six months after delivery are considered part of the purchase price.
Documentation must include:
Major modifications to a wheeled mobility system also require a new seating assessment be completed and submitted with the prior authorization request for the major modification. A request for authorization of the QRP's participation in the seating assessment for the major modification must be included with the prior authorization request for the major modification.
A wheeled mobility system that has been fitted and delivered to the client's home by a QRP and then found to be inappropriate for the client's condition will not be eligible for an upgrade, replacement, or major modification within the first six months following purchase unless there has been a significant change in the client's condition. A significant change in the client's condition must be documented by a physician familiar with the client.
Adjustments
Adjustments must be prior authorized and do not require supplies.
Adjustments within the first six months after delivery, including adjustments to a wheeled mobility system within the first six months after fitting and delivery by a QRP will not be prior authorized. Adjustments within the first six months after delivery are considered part of the purchase price.
A maximum of one hour of labor for adjustments may be prior authorized as needed after the first six months from delivery.
Repairs
Repairs require replacement of components that are no longer functional.
Repairs to client-owned equipment may be prior authorized as needed with documentation of medical necessity. Technician fees are considered part of the cost of the repair.
Providers are responsible for maintaining documentation in the client's medical record specifying the repairs and supporting medical necessity.
Rentals may be prior authorized during the period of repair. Routine maintenance of rental equipment is the provider's responsibility.

Texas Medicaid & Healthcare Partnership
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