Presented by:

1. DME Program Overview Courtney Haynes, BS, RHIT, CPC, MCMP-II Presented by:

2. Mission The mission of the Department of Community Health is to provide access to affordable, quality health care to Georgians through effective planning, purchasing, and oversight. We are dedicated to A Healthy Georgia.

3. Introduction to the DME Program This presentation was designed to illustrate Georgia Medicaid’s definitions, processes, and procedures for Durable Medical Equipment Services. At the end of this presentation you should be able to: • Identify Equipment and Supplies considered to be durable medical equipment. • Understand the process for obtaining durable medical equipment • Be able to locate a provider of DME services in your area • Recognize whether a service is covered through the DME benefit

4. What is Durable Medical Equipment (DME)? Georgia Medicaid defines DME as medically necessary equipment that can withstand repeated use, requires a physician’s order, and is used in the member’s own (non-institutional) residence for the purpose of treating a medical condition, and to improve the quality of life for conditions that may otherwise require the member to admitted to a hospital or other healthcare facility. DME must also: - Be provided by a provider of Durable Medical Equipment who is enrolled in COS 320 - Not be of use in absence of an illness or injury - Have a reasonable useful lifetime of at least three (3)years (excludes supplies) - Be appropriate for use in the home by the member or caregiver, after instruction, without the assistance of a medical professional in most cases. Title or Chapter Slide (use as needed; feel free to delete)

5. Durable Medical Equipment Durable Medical Equipment often includes: Oxygen / Oxygen Related Equipment Ostomy Supplies Automatic External Defibrillators Ventilators Tracheostomy Supplies High Freq. Chest Wall Oscill. Dev Nebulizers Incontinence Supplies IPV Systems Apnea Monitors Breast Pumps Cough Stimulating Devices Wound Care Pumps/Supplies BiPAPs Suction Pumps (wound/resp) Hospital Beds Speech Generating Devices TENS Units Wheelchairs/ Mobility Devices Complex Rehab Equipment Misc. Equipment/Supplies Standers Shower Chairs Walkers Gait Trainers Canes/Crutches Home Phototherapy Services Surgical Dressings Osteogenesis Stimulators Enteral / Parenteral Nutrition Pressure Reducing Support Services

6. Covered Places of Service for DME DME is typically covered in any of the following places of service: 01- Pharmacy 54- Intermediate Care Facility/Mentally Retarded 04-Homeless Shelter 55- Residential Substance Abuse Treatment Facility 09- Prison/Correctional Facility 56- Psychiatric Residential Treatment Center 12- Home 65- End Stage Rental Disease (ESRD) Facility (PEN Only) 13- Assisted Living Facility 14- Group Home 33- Custodial Care Facility Coverage consideration for DME items in a Skilled Nursing Facility (31) or Nursing Facility (32) is limited to the following: • Custom Wheelchairs (Member’s under 21) • Enteral Nutrition (Member’s under 21)

7. Process for Obtaining DME The next several slides will cover the usual process for obtaining durable Medical Equipment Services. 1- Face-to-Face Encounter With Physician 2- Prescription (Dispensing Order) 2- Detailed Written Order and/or Certificate of Medical Necessity 3- PT/OT Evaluation for Complex Rehabilitative Equipment 4- Locating a DME Provider 5- Prior Authorization 6- Delivery of Equipment and/or Supplies 7- Renting / Purchasing Equipment That Requires Ongoing Supplies

8. Documentation- Face-to-Face Encounter The face-to-face encounter can be documented by one of the following: • The use of a Georgia Medicaid Certificate of Medical Necessity which contains fields to be completed by the physician that request the date of the encounter; • Completion of the individual form for verification of the Face-to-Face encounter provided by Georgia Medicaid, in appendix F of the DME Part II Policies and Procedures Manual for DME Services; or • Chart notes or other documentation from the actual Face-to-Face encounter that provide sufficient evidence to support that the encounter occurred and was for the treatment of a condition/illness that supports the need for the DME service, and have been authenticated/dated by the physician..

9. Step- 1 Face-to-Face Encounter With Physician • Step 1 – FACE TO FACE ENCOUNTER: • The member must have seen a physician face-to-face within the six months prior to the start date of an order for DME. • During this visit, the following must have occurred and be documented in the member’s medical record: • Details of an encounter that identify an illness or condition that definitively supports the need for any current or future (within 6 months) written orders. • The encounter must be fully documented and kept on file. The physician must provide this information to the provider of DME services in order to prevent later recoupments and to comply with prior authorization requirements which require that the actual date of the encounter be provided. • The encounter must have the physician’s signature and date clearly identified.

10. Step 2- Dispensing Order (Prescription) • At minimum, all items covered under the DME benefit require a prescription (written order or dispensing order) signed and dated by the treating physician. This type of order is typically only sufficient for items that may be dispensed without a prior authorization, and in cases where great detail is not required (e.g., Nebulizer). • The prescription or dispensing order must contain all of the following information: • The member’s name • The ordering physician’s name • Date of the order (and start date if different) • Supporting Diagnosis • Description of item(s) ordered • Length of need • Quantity ordered (units of each item and number of refills or supply months) • Physician’s signature and date of signature (handwritten or electronic)

11. Step 2 cont.- Detailed Written Order (CMN)

12. Step 3- PT/OT Evaluation (When Required)

13. Step 4- Locating a DME Provider • After an order has been written for equipment or supplies covered through the DME benefit, a supplier should be contacted. The DME provider reviews the order, determines whether they provide the services requested, and then submits a prior authorization, if applicable. • DME providers can be located through the MMIS web portal by following these steps: • https://www.mmis.georgia.gov/portal/default.aspx • Member information • Find a provider • . • or referred by the ordering physician or medical staff who should be reasonably familiar with suppliers in the area.

14. Step 5- Prior Authorization Requests Once a DME Supplier has received an order for medical equipment or supplies, the supplier must submit a request for prior authorization electronically to Alliant GMCF through the web portal at www.mmis.georgia.gov. All supporting documentation required to make a coverage determination (CMN/RX/Supporting Medical Records) must be attached to the request. Note: If the items do not require a prior authorization, then the provider should provide the item and submit a claim for reimbursement if policy guidelines are met. Items that exceed $200.00, require manual pricing, repairs, and all rentals require PA. Obtaining Prior Authorization: DME Provider (COS 320) must submit the request for prior authorization of the services they provide (if applicable)

15. Step 5 Cont.- Prior Authorization Requests • The following steps should be followed to ensure that the prior authorization is complete and a decision can be rendered: • Submit a prior authorization with a start date on or before delivery of equipment/supplies through the web portal to Alliant GMCF • If a Certificate of Medical Necessity is Required make sure it is complete and attached • If a PT/OT evaluation, Speech language pathologist report, Sleep study, O2 Sat/ABG or any other specialty testing/reporting is required, per policy, make sure it is included • Always attach the physician’s order • Make sure the submission contains the appropriate HCPCS codes that describe, most accurately, the item(s) ordered by the physician. • MAKE SURE ALL DOCUMENTATION IS AUTHENTICATED- SIGNED & DATED BY THE PHYSICIAN-

16. Step 5 Cont.- Prior Authorization Requests If all required documentation is included in the request, then the following applies: • The decision for standard DME requests is rendered within 30 days (typically two weeks) • The decision for life-sustaining equipment (ventilators, etc.) is generally complete within 5 business days. Equipment may be delivered prior to the decision for approval, however, the start date on the PA must be on or before the date of delivery, and a claim may not be submitted until the prior authorization has been approved.

17. Step 5 Cont.- Prior Authorization Requests If the PA is approved: • The medical necessity and appropriateness of the equipment has been well documented and supports a positive decision. • The provider should proceed with submitting a claim for reimbursement. If the PA is denied: • Review the rationale for the denial and query the physician if additional supporting documentation is needed to support the medical necessity or appropriateness of the item(s) ordered. • Submit an electronic reconsideration request within thirty days from the date of denial. Make sure to thoroughly review the denial reason and submit all required documentation or information that was identified as the reason for denial.

18. Delivery and Setup of Equipment/Supplies Providers of Durable Medical Equipment and Supplies are responsible for the following at time of delivery: • Delivery • Setup/ Assembly • Training on use of the equipment and/or supplies • Adjustments if required • Follow-up

19. Delivery and Setup of Equipment/Supplies Proof of delivery must be signed and dated by the member or caregiver and kept on file as evidence that the service was performed and is reimbursable by the Department. Methods of permissible delivery include: • Delivery directly to the beneficiary or authorized representative. • Delivery via shipping or delivery service (tracking # Required). • Delivery of items to a nursing facility on behalf of the beneficiary.

20. Proof of Delivery – Directly to Member Method 1: Direct Delivery to the Beneficiary Equipment and supplies may be delivered directly to the beneficiary or caregiver. Proof of delivery must be signed and dated by the beneficiary or caregiver. The proof of delivery must documentation (delivery ticket) must include: • Member’s name • Delivery address • Sufficiently detailed description, with HCPCS codes that identify the item(s) delivered (e.g. brand name, serial number, narrative) • Date delivered • Signature of member or caregiver (if anyone other than the member, must contain relationship to member) • Effective 07/01/2014- The delivery technician or DME representative that delivers the equipment or supplies must sign and date the delivery ticket in addition to the member’s signed and dated confirmation of service.

21. Proof of Delivery- Via Shipping Service Method 2: Delivery Via Shipping/Delivery Service Orders that are shipped vi a shipping/delivery service must be sent with a tracking service included. The order should include both the suppliers own shipping invoice and the delivery services tracking invoice, and a copy must be kept on file for no less than six (6) years. The proof of delivery must contain the following: • Member’s name • Delivery address • Tracking number • HCPCS codes identifying items delivered with detailed description (brand name, serial number, narrative description) • Quantity delivered • Date shipped AND Date delivered • Evidence (Documentation of delivery on file)

22. Proof of Delivery- To Nursing Home Method : Delivery to the Nursing Facility on Behalf of a Beneficiary If equipment or supplies are delivered directly to a nursing facility, the documentation described for Method 1 (see above) is required. If a delivery service or mail order is used to deliver equipment or supplies to a nursing facility on behalf of a beneficiary, then the documentation described for Method 2 (see above) is required. Regardless of the method of delivery, for beneficiaries residing in a nursing facility, there must be information from the nursing facility showing that the item delivered for the beneficiary’s use was actually provided to and used by the beneficiary.

23. Non-Covered Items & Services Examples of items that are non-covered through the DME program include: • Same or Similar Equipment • Upgrades due to changes in technology, etc. • Medical Equipment and Supplies for members admitted to a hospital or other inpatient setting • Medical Equipment and supplies requested for members locked-in to hospice (when the diagnosis is related to the hospice dx) • Equipment and Supplies stated as non-covered, per policy • Exercise equipment • Home modifications • Services restricted to member’s under 21 (when requested for members >21)

24. Improving Communications Keep up with Medicaid updates and initiatives by utilizing the following resources to receive updates as they are relased. • DCH newsletter: DCH-I • Approximately every 6-8 weeks • Sign up • At http://dch.georgia.gov/dch-i • On the signup sheet • Hand me a business card • Banner Messages • https://www.mmis.georgia.gov/portal/default.aspx

25. Part II Policies and Procedures Manual for DME Services For policy and billing questions and inquiries specific to Durable Medical Equipment refer to the Part II Policies and Procedures Manual for Durable Medical Equipment Services at: • https://www.mmis.georgia.gov/portal • Select “Provider Information” tab • Select “Provider Manuals” • Scroll to the appropriate manual “Durable Medical Equipment Services” All program manuals are contained in this centralized location and are listed in alphabetical order. -

26. Schedule of Maximum Allowable Payments for DME Services For pricing questions and inquiries specific to Durable Medical Equipment refer to the Schedule of Maximum Allowable Payments (SMAP) at: • https://www.mmis.georgia.gov/portal • Select “Provider Information” tab • Select “Fee Schedules” • Scroll to the appropriate manual “Durable Medical Equipment Services” All program fee schedules are contained in this centralized location and are listed in alphabetical order. -

27. QUESTIONS ??? Physicians? Insurance? Members? DME Suppliers? Please feel free to ask any additional questions. If you think of something later feel free to email me at chaynes@dch.ga.gov. Case Managers?