|
Attention Medical Equipment providers:
Provider Billing Guide Updates for Medical Equipment and Supplies, Complex Rehabilitation Technology (CRT) and Prosthetics & Orthotics (P&O)
The Health Care Authority (HCA) provides coverage for medical equipment and supplies that meet the definition of medical equipment and supplies listed in WAC 182-543-1000. Items requiring prior authorization (PA) are individually reviewed for medical necessity using evidence-based standards.
The published billing guides list routine medical necessity guidelines, along with specific PA documentation requirements (e.g., HCA required forms), to improve the efficiency of PA reviews. It is important to note that the guidelines do not limit the payment for medical equipment solely to the listed guidelines. Other clinical factors not listed in the billing guides may establish medical necessity, if credible evidence from the electronic health record (EHR) aligns with evidence-based standards of care.
As a reminder, all PA requests for equipment and supplies, CRT, and P&O must be submitted with credible evidence, as outlined in WAC 182-501-0165. The provider is responsible for submitting credible evidence related to the client’s medical condition to support their 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.
Billing Guide and Fee Schedule
See the following guides with the new format that lists routine medical necessity guidelines.
Complex Rehabilitation Technology (CRT) Products & Related Services Billing Guide published November 1, 2024.
Prosthetic and Orthotic (P&O) Devices Billing Guide published November 15, 2024.
The revised guidelines for the Medical Equipment and Supplies Billing Guide will be published by January 1, 2025.
Questions?
Please direct all questions related to this alert to the FFS Durable Medical Equipment (DME) Program.
For specific PA questions, contact the Authorization Services Office (ASO).
|
