Maryland Medicaid

Maryland Medicaid Durable Medical Equipment/Disposable Medical Supplies/Oxygen and Related Respiratory Services (DME/DMS/OXY) Simone Bratton, Chief Introduction The purpose of this presentation is to provide useful information regarding the function of DME/DMS/OXY Unit DME/DMS/OXY What is our mission? What we do?

Who is covered? What is covered? What is the process? Urgent requests Denials FAQs What Is Our Mission? Our mission is to ensure that Maryland Medicaid fee-for-service participants have access to medically necessary medical equipment, supplies, oxygen and related respiratory equipment to meet their health needs in the community.

What We Do Implement, develop and update the Code of Maryland Annotated Regulations(COMAR) DME/DMS-COMAR 10.09.12 ch.aspx?search=10.09.12.* OXY-10.09.18 ch.aspx?search=10.09.18.* What We Do

(contd) Our utilization control agent, Telligen, is now responsible for receiving and processing all durable medical equipment (DME). Currently the Medicaid DME Unit continues to process disposable medical supplies (DMS) and oxygen (OXY) services. DME/DMS/OXY services processed through this unit are for fee for (FFS) services participants only. Managed Care Organizations provide coverage for Health Choice participants. Including services not requiring preauthorization, the Program reimburses

Who Is Covered? All Maryland Medicaid FFS and Healthchoice* participants can receive DME/DMS/OXY services. This includes: Dual eligible participants; participants residing in assisted living facilities; participants residing in group homes; and participants participating in adult day care. *Healthchoice participants can only receive coverage for speech generating (communication) devices through the FFS program. These participants should contact their Manage Care Organization(MCO) for coverage of other services.

Who is covered? (contd) Participants that are NOT eligible for services through the FFS program include: participants residing in nursing homes*; participants receiving inpatient hospital services; participants receiving hospice services; and participants who have family planning only coverage. *Nursing home residents can receive coverage for repairs to wheelchairs that were purchased while the participant resided in the community, prostheses and oxygen.

ALWAYS VERIFY ELIGIBILITY BY CALLING 800.445.1159 What is covered? Maryland Medicaid covers over one thousand items/services when medically necessary. Please see the Approved List of Items(APL) at support/pages/approvedlist.aspx . Providers may also request a copy of the APL at [email protected] or by calling 410767-7283. What is the process?

The process to request coverage for DME/DMS/OXY begins with a face-to-face evaluation from the prescriber. A prescriber is a physician, dentist, podiatrist, physicians assistant, clinical nurse specialist, or nurse practitioner licensed in the state in which the prescriber's practice is maintained who has examined the participant. The faceto-face evaluation must take place within six months of the date of service pertaining to the item request. The evaluation must accompany the DHMH-4527 Preauthorization Request Form. The DHMH-4527 form provides the program with personal demographics of the

participant, prescribing provider information, diagnoses, equipment/supply types and medical justification. The DHMH-4527, face-to-face evaluation and any other documents to support the medical justification of a request are given to an enrolled Medicaid provider of service who then assists the participant with submission to request coverage. What is the process? (contd) Once the provider submits the proper documentation

to the Program, a determination of coverage generally takes up to 30 days. This process can take longer due to the following: If more justification is needed; The DHMH-4527 is incomplete; Prescribers signature is missing, etc. If the request is DME, the provider must submit the request to Telligen. All currently enrolled providers have been trained and are familiar with this process.

Urgent Requests A request for urgent processing occurs when a participant is being discharged from a long term care facility or from a hospital and prescribed medically necessary items must be in the home prior to the actual discharge. In some cases, an item may be needed to train a participant on its use prior to discharge, for example a manual or motorized wheelchair. When an urgent request is needed, the DHMH-4527, supporting documents such as a signed discharge plan and the reason for the urgent request can be faxed to the program using 410-333-5052. DME items will be transmitted to Telligen for processing.

Denial of Coverage A participant may be denied for coverage of services for the following reasons: The item requested does not meet the definition of medical equipment of DME, DMS or OXY; Medicaid eligibility is cancelled prior to the date of service; The medical justification presented to support the request is insufficient; PRN is not an accepted medical justification; Medical necessity of an item could not be established in part because the requested information was not provided;

The item requested is not medically necessary. A participant may appeal within 90 days of the date of denial pursuant to COMAR 10.01.04. Denial of Coverage (contd) A provider may be denied coverage of services for the following reasons: The participant is enrolled in a MCO or long

term care facility; The request is not submitted in a timely manner; The provider is not enrolled to supply this service; The service approval has been given to another provider. A signed letter of intent from the participant must be forwarded. A provider may appeal within 30 days of the FAQs Where can I get provider information such as Approved List of Items,

transmittals/memos, and PA instructions /request submission? Please visit https:// aspx Where should the provider send PA requests? Please send requests to the address at the bottom of the request form (DHMH-4527) How are providers notified when a PA has been received? Once received, and entered in to the system, the provider receives an auto generated letter with the assigned PA number If this item is DME, the provider will receive a reference that will be used to access Telligens system for status checks.

FAQs (contd) How long does it take to process PA request? It generally takes 30 days to process a request How can I check the status of a request? You can request status by faxing the information to 410.333.5052 or emailing [email protected] * (Providers will use their Telligen reference number to request status) How can I contact the Unit? Please call 410-767-7283 to speak with a staff specialist, or via

email at [email protected] *Please allow 30 before requesting status of a received PA FAQs (contd) How can I find a DME Provider in my area? You can call the unit, and the administrative staff will assist you with your request Who do I call for issues with the processing of claims? You can call Provider Relations at 410-767-5503

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