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Attention providers:
Prior Authorization and Proof of Delivery Requirements for Medical Equipment and CRT
The Health Care Authority (HCA) is issuing this notice to clarify existing requirements for prior authorization (PA) and proof of delivery for medical equipment and complex rehabilitation technology (CRT). This is not new policy.
Prior Authorization:
Under WAC 182-543-7100, providers must obtain PA for certain items and services before delivering them to the client, except for dual-eligible Medicare/Medicaid clients when Medicare is the primary payer.
Note: Billing HCA is permissible only after the item or service has been delivered to the client.
Proof of Delivery:
Under WAC 182-543-2200, the provider must furnish proof of delivery. If the provider uses a delivery/shipping service, the tracking slip is the proof of delivery. If the provider/supplier does the delivering, the delivery slip is the proof of delivery. Providers must obtain PA, when required, before delivering the item to the client.
Note: HCA will not accept delivery receipts or attestations with modified or tampered delivery dates.
Loaner Equipment and Rentals: Under WAC 182-543-2000, providers must deliver new medical equipment, not rentals, and provide full manufacturer and dealer warranties. Loaner equipment provided to a client before PA has been approved, is considered a rental. Rentals and loaners may not be delivered to the client as new equipment.
For example, if a custom wheelchair is fitted for a client, it cannot be delivered as a loaner or rental before PA is approved. Doing so constitutes an unauthorized service and will lead to a denied PA. Billing rental or loaner equipment as new is unauthorized and may be considered fraudulent billing.
If a provider fails to obtain PA for a service, they cannot bill the client for the service. Additionally, the provider is not entitled to a hearing option because the client is not considered aggrieved by the lack of PA. Services rendered without the necessary PA are administratively denied, and providers are prohibited from holding clients financially responsible for such services.
Other applicable references:
Billing Guide and Fee Schedule
HCA billing guides describe the PA and proof of delivery processes. However, clarifications and updates will be included in the publication scheduled for July 1, 2024. See HCA’s Provider billing guides and fee schedules, under Complex Rehabilitation Technology and Medical Equipment and Supplies.
For more details, please refer to the specific WAC sections or contact the HCA Medical Equipment and CRT Program at DME@hca.wa.gov.
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