Policy Updates

 

Effective with dates of services on or after April 1, 2012, the South Carolina Department of Health and Human Services (SCDHHS) will make the following policy updates.

 

  1. Prior Authorization and Reconsideration Process

 

All Prior Authorization (PA) requests for Durable Medical Equipment (DME) equipment or supplies must include the Medicaid PA Form, the Medicaid Certificate of Medical Necessity (MCMN), and the original or a legible copy of the patient’s prescription.  If the PA is denied, providers may request a reconsideration of the decision.  Requests for reconsiderations must be submitted in writing within thirty (30) calendar days of receipt of the denial.  The reconsideration request must include a copy of the denial letter and any documentation not previously submitted that supports the medical necessity for the equipment requested.  If the original denial is upheld, providers may exercise their right to an appeal as outlined in Section 100 of the Medicaid DME provider manual located on our website at http://www.scdhhs.gov

 

  1. Required Documents for Manually Priced DME Procedure Codes

 

To ensure accurate payment of DME manually priced procedure codes and codes Not Otherwise Classified (NOC), providers must submit an invoice that contains Manufacturer Suggested Retail Pricing (MSRP) for the items billed.  If submitting an internet "screen print”, a signature is required certifying the date, quantity, cost, and description of items being billed.  Medicaid will reimburse cost plus twenty-five (25) percent.  Claims submitted with documents other than an Invoice or a signed document as indicated above will be rejected.

 

  1. Update to DME Procedure Codes

 

The table below lists DME codes that will be modified, which include codes that now require a PA, codes that no longer require a PA, codes that no longer require the MCMN and codes that have been deleted.  These codes will be updated in the DME provider manual.

 

PA Removed  (Send claim in with MCMN)

CMN Removed  (Codes can be filed electronically and MCMN kept on file)

PA Required

Deleted Codes

A4280

A4604

E1225

E2204

E2312

E1310

A6441

A6441

E1226

E2222

E2313

 

B4103

A6452

E1841

E2226

E2321

 

B4157

A6453

E2201

E2392

E2322

 

B4162

A6454

E2202

E2394

E2375

 

E0640

A8000

E2203

E2395

B9998

 

E0565

A8001

 

E2622

B8189

 

E0655

E0168

 

K0733

L0637

 

E0660

E0562

 

L3455

L1832

 

E1031

E0621

 

 

 

 

E1038

E0911

 

 

 

 

E1039

E0912

 

 

 

 

T5001

E0956

 

 

 

 

 

  1. Manual and Power wheelchairs

 

SCDHHShas revised the Manual and Power Wheelchair section of the DME provider manual.  This includes but is not limited to face-to-face examination criteria, mobility evaluations, and physician prescription information.  Please refer to the Durable Medical Equipment manual, Section 200, located on our website at http://www.scdhhs.gov.

 

If you have any questions regarding the contents of this bulletin, please contact your Program Manager in the Office of Hospitals and Durable Medical Equipment at (803) 898-2665.  Thank you for your continued support of the Medicaid program.

 

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