Ala. Admin. Code r. 560-X-13-.03

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-13-.03 - Method Of Requesting DME, Supplies, Appliances And POP

(1) A written order or a signed prescription (as defined by the Medicare Program Integrity Manual Chapter 5) signed by the prescriber is required for covered items. An EPSDT or Patient 1st primary physician (PMP) referral may be submitted as an order when written according to practice guidelines and state or federal law and must include the date and signature of the prescriber, the item(s) ordered and the recipient name. For acceptable formats of provider signature, refer to Medicaid Administrative Code, Rule No. 560-X-1-.18.

(2) A prescription or order is considered to be outdated by Medicaid when it is presented to the provider or Medicaid's fiscal agent past 90 days from the date it was written.

(3) Medicaid considers a prescription to be valid for the dispensing of supplies for a period of twelve months. After the twelve month period of time, the recipient must be reevaluated by the prescriber to determine medical necessity for continued dispensing of medical supplies.

(4) Certain DME, supplies and appliances require prior authorization by Medicaid. Please refer to Chapter 14, DME, of the Medicaid Provider Manual published on Medicaid's website. Repairs or replacement of parts, after the first year the equipment or appliance is issued, require prior authorization unless otherwise specified by Medicaid. A provider's failure to go through the process of obtaining prior authorization for repairs or replacement does not by itself constitute a non-covered service.

(5) Procedures for requesting and dispensing DME, supplies and appliances that require a prior authorization are as follows:

(a) The prescriber must complete and sign a written order or prescription and give to the recipient or sponsor to take to the provider of their choice. The prescriber may also fax the prescription or order to the provider of the recipient's choice.

(b) The provider must submit the following documentation by electronic submission, fax or mail to the Medicaid fiscal agent:

1. the appropriate Alabama Prior Review and Authorization Request Form,

2. the EPSDT or Patient 1st PMP Referral Form, if applicable,

3. all necessary documentation to justify medical necessity, and

4. current prescription or order.

(c) Medicaid or its designee will review the request and assign a status of approved, denied or pending.

1. If the request is approved, the provider will receive an approval letter with the ten-digit prior authorization number.

2. If the request is denied, written notice will be sent to the provider and the recipient indicating the reason(s) for denial. Information giving them their right to appeal is also included in this notice.

3. If the request is placed in pending or conditionally approved status, the prior authorization letter will provide information and a timeframe for submission of the invoice.

(d) All prior authorization requests for DME must be received by the Medicaid fiscal agent within 30 calendar days after equipment is dispensed. All prior authorization requests received beyond the 30 calendar days after equipment is dispensed will be denied.

(e) The provider may not bill the recipient for an item for which a prior authorization has been denied due to provider error or the provider's failure to submit the necessary medical documentation for the prior authorization request.

(6) Suppliers requesting approvals for medical items must provide Medicaid with an expected date of delivery. For medical items approved, Medicaid will indicate the time frame allowed for providers to dispense equipment on the approval letter.

(a) When a provider is unable to dispense equipment within the timeframe specified on the approval letter, an extension may be requested with written justification as to the specific reason(s) why the equipment cannot be supplied timely. All requests for extensions must be submitted to Medicaid prior to the expiration date indicated on the approval letter.

(b) Medicaid will cancel conditional approvals (PA's in "pending" status) for medical items that are not dispensed timely when there is no justifiable reason for delay.

(7) Procedures for requesting and dispensing DME, supplies and appliances that do not require a prior authorization are as follows:

(a) It is the responsibility of the recipient or authorized representative to obtain the signed prescription or order from the physician and take to a participating provider.

(b) Upon receipt of the prescription or order, the provider must:

1. verify Medicaid eligibility. Recipient's eligibility must be verified on a monthly basis. Medicaid will not reimburse providers for items supplied to recipients in months where recipients have no eligibility;

2. obtain necessary managed care or EPSDT referrals;

3. furnish the covered item(s) as prescribed;

4. collect the appropriate co-payment amount;

5. retain all documentation, including, but not limited to, the prescription or order, referral forms, PA forms, etc. on file for a period of three years plus the current year; and

6. submit the proper claim form to Medicaid's fiscal agent.

(8) DME, supplies, and appliances not listed as covered services in Chapter 14, DME, of the Medicaid Provider Manual may be requested for coverage by submitting the request to Medicaid for review and consideration. It will be the provider's responsibility to supply Medicaid with the necessary medical documentation to support the medical necessity of the requested item(s).

(9) Automatic refills are not permitted by the Medicaid Agency. Violations may result in unauthorized charges. The provider may be held liable, or Medicaid may recoup the unauthorized charges, or cancel the provider agreement.

Ala. Admin. Code r. 560-X-13-.03

Rule effective October 1, 1982. Amended: Effective November 11, 1985; January 13, 1993. Amended: Filed December 12, 2008; effective January 16, 2009. Amended: Filed May 11, 2012; effective June 15, 2012.

Amended by Alabama Administrative Monthly Volume XXXIV, Issue No. 04, January 29, 2016, eff. 2/25/2016.

Author: Kelli Littlejohn Newman, PharmD, Director, Clinical Services

Statutory Authority: State Plan Attachment 3.1-A; 42 CFR §440.70; Title XIX, Social Security Act.