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TO:                 All Durable Medical Equipment (DME) Providers

 

FROM:           Paul swatsenbarg, Deputy Administrator

   

 

Effective January 1, 2002, the following definition for prior authorization and valid prior authorization request will be applicable for durable medical equipment and supplies.

 

Prior Authorization: A written, FAXED, or electronic approval from the Department that permits payment or coverage of a medical item or service that is covered only by such authorization.  Medicaid payment will be denied for the medical item or service or portions thereof, which were provided prior to the submission of a valid prior authorization request.

 

·        The provider may not bill the Medicaid participant for equipment and/or supplies not reimbursed by Medicaid solely because the prior authorization was not requested or obtained in a timely manner.

·         Requests for prior authorization for items or services provided on a weekend or holiday must be received on the next business day after the item or service was provided.

·        An exception may be allowed on a case-by-case basis where despite diligent efforts on the part of the provider to timely submit a request, or events beyond the provider’s control prevented it. 

·        Equipment and/or supplies to an individual will be deemed prior approved if the individual was not eligible for Medicaid at the time these items were provided, but was subsequently found eligible pursuant to IDAPA 16.03.05.051.03.

Ø       and the medical item or service provided is approved by the Department by the same guidance that applies to other prior authorization requests for medical necessity.

Ø       and is submitted within 30 days of when the provider becomes aware of the individual’s Medicaid eligibility. 

 

Valid Prior Authorization Request: A prior authorization request from a provider of Medicaid for services that contains all information and documentation as required by the rules to justify the medical necessity, amount of and duration for the item or service.

 

·        Please refer to your Provider Handbook for a list of the types of items that require prior authorization and the documentation elements required.

·        You can call EDS at 1-800-685-3757 to inquire whether the code requires prior authorization        

·        Medical necessity documentation required is documentation that the client meets the criteria set forth in the Medicare DMERC Supplier Manual.

·        For those items that do not have criteria in that manual, submit documentation from the physician, therapist, etc. that documents the reasons the equipment is medically necessary for that particular client and the length of need.

 

If you have questions, please contact Dorrie Phillips toll free at 866-205-7403.  Thank you for your continued participation in the Idaho Medicaid Program.