News

CMS wades in with 12 more states after testing the water with seven.

Date Published: August 01 2014

At A Glance: Prior Authorization Demo Expansion, October 1, 2014

What: The Prior Authorization Demonstration Project for Power Mobility Devices currently in effect for seven states (Florida, Texas, California, Illinois, New York, Michigan, North Carolina) expands to 12 additional states.

What you need to know:  Prior Authorization starts October 1, 2014 in the twelve expansion states.  Beginning January 1, 2015, a Medicare payment reduction of 25% will be assessed for each payable claim submitted without first initiating a prior authorization request (in non-CBA areas).  

Who: There are three new states in each Jurisdiction:              

                                   DME MAC A:  Pennsylvania, Maryland, New Jersey

                                   DME MAC B:  Ohio, Indiana, Kentucky

                                   DME MAC C:  Louisiana, Georgia, Tennessee

                                   DME MAC D:  Missouri, Washington, Arizona 

Affected PMD: Group 1 Power Operated Vehicles (K0800 thru K0802 and K0812)

                                   All standard power wheelchairs (K0813 thru K0829)

                                   All Group 2 complex rehab power wheelchairs (K0835 thru K0843)

                                   All Group 3 complex rehab power wheelchairs w/o power options (K0848 thru K0855)

                                   Pediatric power wheelchairs (K0890 and K0891)

                                   Miscellaneous power wheelchairs (K0898).

How it Works: The treating practitioner completes the 7 element order, face-to-face encounter and medical necessity documentation which the DME provider uses to complete the Detailed Product Description. The DME supplier submits the Prior Authorization request, written order and relevant documentation supporting Medicare coverage of the PMD to the regional DME MAC for medical review.  Notification of the medical reviewer’s decision (approximately 10 days) is provided to the treating practitioner, supplier and beneficiary. Subsequent prior authorization requests may be submitted for initial non-affirm decisions.

How best to prepare: Ensure the F2F paperwork from your referral sources is comprehensive, compliant and complete by subscribing to DMEevalumate.com. Bring your physicians a F2F tool with a Prior Authorization 99% affirm rate, when compared with the national average 50% denial rate. Physicians and practitioners use the online program during F2F exams for PMDs. The program addresses pertinent questions and generates accurate paperwork documenting medical necessity in the format Medicare requires. Orders and F2F notes are compatible with all Electronic Health Records.

Call (800) 986-9368 today to schedule a free webinar and see if DMEevalumate.com may be a good fit for your organization. Go to www.dmeevalumate.com/cms for more information.

                                    

Back to news