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Attention Medical Equipment and Supplies providers:
Provider Billing Guide Updates for Medical Equipment and Supplies regarding bathroom equipment
The Health Care Authority (HCA) Apple Health fee-for-service (FFS) provides coverage for medical equipment and supplies (MES) that meet the definition listed in WAC 182-543-1000. MES items requiring prior authorization (PA) are individually reviewed for medical necessity using evidence-based standards.
Bathroom equipment that meets the definition of medical equipment is covered by Apple Health FFS/HCA when determined to be medically necessary. Medical necessity may apply to acute and/or chronic medical conditions.
In general, to meet medical necessity requirements, a client must be at risk of falls or other injuries while performing activities of daily living (ADLs) necessary to maintain or improve their health, such as bathing and toileting. Additional routine medical necessity guidelines will be updated in the MES billing guide, effective January 1, 2025.
Reminders for providers requesting authorization:
- PA requests for bathroom equipment must include a Bathroom Equipment form, HCA 13-872
- All equipment requests 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 medical necessity.
- Supporting records may include physiological description, laboratory findings, imaging reports, patient records, and if necessary, photographs or videos.
For more information on prior authorization, see the Step-by-step guide for prior authorization | Washington State Health Care Authority.
Forms may be downloaded from Forms and publications | Washington State Health Care Authority.
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 Medical Equipment and Supplies Billing Guide for the new format that lists routine medical necessity guidelines. The revised 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).
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