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Attention providers:
Fee for Service (FFS) Documentation Requirements for Prior Authorizations for Medical Equipment, Supplies, Complex Rehabilitation Technology (CRT) and Prosthetics & Orthotics (P&O)
Effective immediately, the Health Care Authority (HCA) FFS Medical Equipment, Supplies, Prosthetics & Orthotics programs will require that all prior authorization (PA) requests for medical equipment, supplies, Complex Rehabilitation Technology (CRT), and Prosthetics & Orthotics (P&O) be submitted with credible evidence, as outlined in WAC 182-501-0165.
Why this “new” requirement?
This is not a new requirement, but rather a clarification of the existing requirements outlined under WAC 182-501-0165(5), “The agency considers and evaluates all available clinical information and credible evidence relevant to the client's condition. The provider responsible for the client's diagnosis, or treatment, or both, must submit with the request credible evidence specifically related to the client's condition…”
Credible evidence consists of medical record documentation sourced from the client’s Electronic Health Record (EHR). The documentation should substantiate medical necessity, coverage criteria, and support letters of medical necessity. In accordance with Centers for Medicare & Medicaid Services (CMS) guidelines for Medicaid documentation, the client's medical record must adequately demonstrate their condition, justify the prescribed items and quantities, and specify the frequency of use or replacement, if applicable. Submission of an HCA form, supplier statement, or provider attestation alone, even if endorsed, is insufficient without accompanying supporting medical record information.
The provider is responsible for submitting credible evidence related to the client’s medical condition, that supports justification for medical necessity. The records may include physiological description, laboratory findings, imaging reports, patient records, and if necessary, photographs or videos. It's also important to understand that under WAC 182-500-0070, medical necessity means that there is no other equally effective, more conservative, or significantly less costly course of treatment available or suitable for the client requesting the service.
What medical records are needed?
The provider is responsible for deciding which documentation to submit, based on the justification of medical necessity. Examples of medical record documentation include, but are not limited to, provider assessments and orders, therapy care plans and progress notes, nursing progress notes, and nursing facility care plans. If the submitted documentation does not support the medical necessity for the requested medical equipment, the equipment will not be considered medically necessary.
How will HCA respond to prior authorizations that do not include medical records?
Effective July 1, 2024, HCA will reject medical equipment, supplies, CRT and P&O prior authorizations (PA) that do not include medical records to support agency required forms and letters of medical necessity. If rejected, suppliers may resubmit PA requests with the required medical record documentation.
Billing Guide and Fee Schedule
HCA will revise the Medical Equipment & Supplies, Complex Rehabilitation Technology (CRT) and Prosthetics & Orthotics Billing Guides to reflect this policy. See HCA’s Provider billing guides and fee schedules, under Medical Equipment & Supplies, CRT and Prosthetics & Orthotics.
Questions?
Please direct all questions related to this alert to the Fee for Service Durable Medical Equipment (DME) Program at DME@hca.wa.gov.
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