Simone Bratton Chief Introduction The purpose of this presentation is to provide useful information regarding the function of DMEDMSOXY Unit DMEDMSOXY What is our mission ID: 775853
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Maryland Medicaid
Durable Medical Equipment/Disposable Medical Supplies/Oxygen and Related Respiratory Services (DME/DMS/OXY) Simone Bratton, Chief
Slide2Introduction
The purpose of this presentation is to provide useful information regarding the function of DME/DMS/OXY Unit
Slide3DME/DMS/OXY
What is our mission?
What we do?
Who is covered?
What is covered?
What is the process?
Urgent requests
Denials
FAQs
Slide4What Is Our Mission?
Our mission is to
ensure that Maryland Medicaid fee-for-service
participants
have access to
m
edically
n
ecessary
medical equipment,
supplies
, oxygen and related respiratory equipment to meet their health needs in the
community.
Slide5What We Do
Implement, develop and update
the Code of
Maryland Annotated Regulations(COMAR)
DME/DMS-COMAR 10.09.12
http://www.dsd.state.md.us/comar/SubtitleSearch.aspx?search=10.09.12.*
OXY-10.09.18
http://www.dsd.state.md.us/comar/SubtitleSearch.aspx?search=10.09.18.*
Slide6What We Do (cont’d)
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 over $45M annually.
Slide7Who 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.
Slide8Who is covered? (cont’d)
Participants that
are
NOT
eligible for services through the FFS program include:
participants
residing in
n
ursing 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
Slide9What is covered?
Maryland Medicaid covers over one thousand items/services when medically necessary. Please see the Approved List of Items(APL) at
https://mmcp.health.maryland.gov/communitysupport/pages/approvedlist.aspx
.
Providers may also request a copy of the APL at
mdh.dcss@maryland.gov
or
by calling
410-767-7283.
Slide10What 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, physician’s 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 face-to-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.
Slide11What is the process? (cont’d)
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;
Prescriber’s 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.
Slide12Urgent 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.
Slide13Denial 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.
Slide14Denial of Coverage (cont’d)
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 date of the denial pursuant to COMAR 10.01.04.
Slide15FAQs
Where can I get provider information such as Approved List of Items, transmittals/memos, and PA instructions /request submission?
Please visit
https://
mmcp.health.maryland.gov/communitysupport/pages/approvedlist.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
Telligen’s
system for status checks.
Slide16FAQs (cont’d)
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
mdh.dcss@maryland.gov
* (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
mdh.dcss@maryland.gov
*
Please allow 30 before requesting status of a received PA
Slide17FAQs (cont’d)
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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