Children’s Medical ServicesBranch E-47 SAR System Authorization of Medical Supplies
Medical Supplies vs. Durable Medical Equipment (DME) Accessories • Medical supplies are generally considered disposable, though sometimes may be used more than once. • DME accessories are used as an integral part of a piece of DME. • DME accessories may be reused for longer periods of time. • DME accessories use a DME code, e.g. E0450.
What are Valid Medical Supply Codes? • 4 numeral digits plus an alpha character, eg. 9987K as listed in Medi-Cal Manual. • First 2 digits are always “99”. • 2 additional alpha characters added at the end of the 5 digit code represent the manufacturer’s code, e.g. 9987KRM. • Requests using only a 5 digit code may be authorized, without regard to the 2 digit manufacturer code.
What are Valid Medical Supply Codes? • 11 digit NDC code for diabetic medical supplies, e.g. 00193391125. • Effective Nov. 1, 2004, Department has negotiated contracts with diabetic supply manufacturers. • Diabetic medical supplies with NDC/UPC codes are lancets and test strips.
What are Valid Medical Supply Codes? • For dates of service on or after Nov. 1, 2004, requests for lancets and test strips without NDC/UPC codes are not acceptable. • NDC codes may only be authorized to contracted pharmacies. • NDC codes for diabetic supplies may be found in SAR Formulary. • NDC codes for diabetic supplies may be authorized in SAR system under Medical Supplies.
Quiz:Medical Supply or DME Accessory Code? • A4660 • 9928D • RM9987K • 00193654621 • X3699 • DME Accessory • Medical Supply • Medical Supply • Diabetic Medical Supply • DME Accessory
What if a Specific Medical Supply Code Does Not Exist? • Miscellaneous codes are listed in the Provider Manual. • May not use the misc. code if a specific code generally describes the item. • Incorrect use of a misc. code may result in non-payment.
What About an Unlisted Code or Unknown Manufacturer? • 9999A = Unlisted medical supply. • ZZ manufacturer code not listed in CMS Web. • These codes may be used when no listed code applies and the misc. code in the general item category does not apply. • Most often used with new item. • Requires “by-report”, listing item description, manufacturer, and item number in special instructions.
What if Code is Not Listed in the Web-based System? • Don’t guess, • Contact provider to obtain correct code, • Clarify if requested item is medical supply or DME item or accessory,
What if Code is Not Listed in the Web-based System? • Check to see if there is a miscellaneous item supply code listed, • Inquire if 9999A is appropriate, • Refer to Medi-Cal Allied Health Provider Manual for list of all medical supply codes at www.medi-cal.ca.gov.
UNITS • For medical supply codes (4 numeric digits followed by an alpha character), multiply out total number to be authorized within the effective dates, e.g. 100 gloves per mo. for 6 mos. = 600 units. • For NDC codes (lancets and strips), enter # of fills + refills.
QUANTITY (Pharmacy Only) • Quantity field is only used for NDC codes. • Only NDC codes requiring prior authorization are drugs on the excluded list and diabetic supplies (lancets and strips). • Enter number to be authorized per unit in quantity field.
Medi-Cal Manual Example KARAYA GUM POWDER Karaya Gum Powder, Karaya Paste and Stomahesive Paste/Powder is limited to a cumulative total of no more than 12 ounces in a 30-day period, per recipient, without prior authorization. † Regular1.05 ounces9981L ounces † 2.45 – 4.20 ounces9981M ounces † 11.90 – 16.80 ounces9981N ounces † Sterile1.05 ounces9981P ounces † 2.45 – 4.20 ounces9981R ounces † 11.90 – 16.80 ounces 9981S ounces †