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Provider update: November 6, 2020

To: ADvantage DME and Case Management Providers

Subject: DME Changes

Date: November 6, 2020

As noted in the bulletin dated 6/1/2020, many DME items became available for coverage under the ADvantage Member’s SoonerCare benefit instead of under the ADvantage Waiver as of 8/1/2020.

MSU AA has continued approving many items on ADvantage Member’s service plans during the transition to the new process. Beginning with any plan submissions dated on or after 12/1/2020, MSU AA will require appropriate documentation of an OHCA denial prior to approval of the SoonerCare benefit covered item on the ADvantage plan.

Below are topics addressed in this bulletin (click on topic to jump to that location):

Items still covered under ADvantage Waiver
Incontinence Supplies
Nutritional Supplements
DME Codes in Harmony
Existing Prior Authorization Lines in Harmony
DME Requirements at Reassessment
State Plan Personal Care (SPPC) Members
DME Pricing Methodology
Contacting OHCA for PA issues/questions
Ordering Physician
Environmental Modifications
Rural vs Non-Rural Cost
Items previously approved under code E1399
Documentation in Harmony
Documentation of ADvantage covered items 

Documentation of ADvantage covered items
Documentation of Items covered under the Member’s SoonerCare benefit
Documentation for Items denied by OHCA under Member’s SoonerCare benefit

Items still covered under ADvantage Waiver

  • A document entitled “ADvantage Covered DME Products” has been added to the Library site and will be updated if/when changes in covered items are identified.
  • The document and a copy of this bulletin are located in the Library Site under the newly added “DME Information” folder. That folder may also be accessed by clicking on this link: DME Information
  • Items on the “ADvantage Covered DME Products” document are not required to go through the OHCA approval process and instead may be requested on the Member specific plan for ADvantage coverage as appropriate.
  • All DME products not listed on the “ADvantage Covered DME Products” document will need to be submitted through the Member’s SoonerCare benefit. This process will be done by the DME provider with appropriate documentation obtained from the Member’s Physician

Incontinence Supplies

  • DME Providers should use the HCA-52A form.
    The form may be located on the OHCA website by clicking on the link below.

  • Two documents with specific information regarding Prior Authorization guidelines for incontinence supplies may be located on the OHCA website by clicking on the link below.
  • If incontinence supplies are denied by OHCA and submitted for approval under the Members ADvantage Plan, the following are required:
    • Copy of OHCA denial, and
    • Copy of HCA-52A form.
    • An example of how to request items denied by OHCA is included in the "Documentation in Harmony" section.
  • Incontinence supply requests must use the HCA-52A form no matter the number or type of supplies requested.

Nutritional Supplements

  • Oral Nutritional Supplements will no longer be authorized using the T1999 code.
  • Effective with any plan submissions dated on or after 12/1/2020, the appropriate B Code with modifier listed on the “ADvantage Covered DME Products” document should be used.
  • An update has been made to the “Order for Nutritional Supplements” word merge to better document the # of cans per day and how many cases that would require per month.
  •  *Note: The “ADvantage Covered DME Products” document lists the number of cans that are in a case for each product.
  • An example of how to add a planned service line for nutritional supplements is included in the "Documentation in Harmony" section.

DME Codes in Harmony

  • We are in the process of adding all appropriate DME codes to Harmony.
  • If, when completing a Member’s Plan in Harmony, a code is needed that has not yet been added for a specific provider the CM should send a PQ indicating the DME Provider Name and code that needs to be added.
  • *Note: Some rates may show incorrectly, but an update has been made in the Harmony system such that rates will default to the appropriate rate set by OHCA when it enters the Medicaid Management Information System (MMIS).

Existing Prior Authorization Lines in Harmony

  • Member PAs that are already authorized in Harmony will remain valid through the current end date. When the authorization expires or a plan change is needed, the DME item will need to be covered under the SoonerCare benefit unless it is listed in the “ADvantage Covered DME Products” document.
  • If a PA is authorized under the ADvantage Plan and is later approved for an overlapping time under the SoonerCare benefit, OHCA is notifying MSU AA so that the ADvantage line can be ended as appropriate.

DME Requirements at Reassessment

  • Because Members’ situations/diagnoses may change over time, DME items authorized through ADvantage on the previous year’s plan that are eligible for coverage under SoonerCare must be submitted for authorization through SoonerCare.
  • If DME items are subsequently denied by OHCA, they may then be submitted for authorization under ADvantage per the instructions located at Documentation for Items denied by OHCA under Member’s SoonerCare benefit.

State Plan Personal Care (SPPC) Members

  • State Plan Personal Care (SPPC) Members are eligible for DME items that are covered by SoonerCare. If the Member needs a DME product they should be referred to their physician to start the process. DME items do not need to be listed on the Plan in Harmony for SPPC Members.

DME Pricing Methodology

  • ADvantage will follow OHCA pricing methodology for ADvantage covered items with an established cost.
  • If an item is listed with “$0.00 cost” or “Contact DME for Price” on the ‘ADvantage Covered DME Products” document, then manual pricing will be allowed per OHCA rules.

Link to the OHCA fee schedules: SoonerCare Fee Schedule

*Note: If an item does not appear on this fee schedule but appears on the regular 1/1/2020 TXIX fee schedule, it should be manually priced.

Contacting OHCA for PA issues/questions

  • If a DME Provider needs to contact OHCA regarding a DME issue they may send an e-mail to DMEAdmin@okhca.org.
    • Include provider name and provider # with inquiry to expedite a response from OHCA staff.
    • *Note: This may include issues with obtaining orders from a specific physician.
  • If a DME Provider submits a prior authorization request (PAR) for any item through the OHCA portal and the PA is automatically cancelled due to the Member being a Medicare Recipient, the DME should send an email explaining the issue to DMEAdmin@okhca.org along with the PA number. OHCA is working on a fix to this issue in their system to prevent automatic cancellation of these requests.

Ordering Physician

  • The ordering physician must be a Medicaid contracted physician for the DME Provider to be paid for the item.
    • *This applies to both DME items approved on the SoonerCare benefit and on the Members ADvantage Waiver benefit.

Below is a link to the OHCA Provider Directory to see if a specific Provider is Medicaid contracted.
Provider Search

Environmental Modifications

  • There are no changes to the prior process for requesting Environmental Modifications on a Members Plan.

Rural vs Non-Rural Cost

  • Some DME items have a different rate if the Member is in a rural versus a non-rural county.
  • There is no modifier for rural versus non rural such as there is for Case Management services.
  • The appropriate rate is determined automatically when the claim is filed by the DME based on the Member’s address.

Items previously approved under code E1399

  • E1399 was previously used for several items as it is a general code.
  • Effective with plan submissions dated on or after 12/1/2020, E1399 should only be used for the following:
    • Installed Handheld Shower
    • Installed Grab Bars (not in the bathroom)
    • Adaptive utensils
  • The following codes should be used for additional items previously approved under E1399:
    These Items are now covered under TXIX:
    • Bed Cane = E0100
    • Bed wedge = E0190
    • Surgical Masks = A4928

These Items are still covered under ADvantage but must be requested using the codes listed below:

  •  Sock Aid/Shoehorn = A9281
  • Hip Kit = A9281
  • Gloves = A4927 (also covered under TXIX for specific criteria)
  • Reacher = A9281
  • Gait Belt = E0705
  • Over-bed Table = E0274
  • Bottom Buddy = A9281
  • Electronic Medication Compliance Management Device = T1505
 

Documentation in Harmony

Documentation of ADvantage covered items

  • Case Managers (CMs) will continue to add ADvantage Covered DME products listed on the “ADvantage Covered DME Products” document to Planned Service Lines in Harmony.
  • The DME provider will be added to the Provider Enrollment Tab to allow the Provider to obtain the ADvantage PA number.
  • The planned service line will continue to list the actual DME Provider Name.
  • See below for example of planned service line for Member requiring 2 cans of Ensure orally per day.
    • 2 cans x 30 days (average days in a month) = 60 cans per month
    • 60 cans per month / 24 cans per case = 2.5 cases per month which will be rounded up and entered as 3 cases in Harmony. 

Documentation of Items covered under the Member’s SoonerCare benefit

  • CMs will continue to add SoonerCare covered items to the Planned Service Lines in Harmony.
    • The planned service line will use the code with the State Paid ‘ZS’ modifier.
    • The provider listed will be “Other” (similar to adding other non-waiver paid items such as informal supports or transportation)
    • The name of the DME provider will be documented in the comments box.
    • The DME provider shall NOT be added to the Provider Enrollment Tab.
      • All communication regarding non-ADvantage covered items must be made directly to the provider such as through telephone or email.
      •  SoonerCare DME Providers do not require Harmony access to obtain the PA number for SoonerCare covered DME items.
      • Entities not providing ADvantage covered services to a member must not have access to confidential Member information included in the Harmony record.
    • See below for example of a planned service line for a Member needing adult size pullups (80 per month) under their SoonerCare benefit: 

Documentation for Items denied by OHCA under Member’s SoonerCare benefit

If a DME item is not approved under the SoonerCare benefit, the DME may reach out to the Member’s Case Manager for assistance obtaining additional documentation from the Member’s primary physician; or, the DME may request the item be added to the planned services for consideration of payment through the ADvantage Waiver.

  •   *Note: Members may also follow the appeal process if Denied a specific DME product through SoonerCare, but this is not required prior to requesting the item be paid under the ADvantage Waiver.
  • The specific DME provider will be added to the Provider Enrollment Tab after the DME item is authorized to allow the Provider to obtain the ADvantage PA number.
  • Request for approval under ADvantage Waiver will be submitted in Harmony following the Process for a “Plan Change” request with the following additional actions:
    • The OHCA Denial letter is attached to a Plan Note using a note type of “Documentation” and Note Sub-Type of “TXIX DME Denial”. 
  • CMs will change the SPA Review status on the line with the ZS modifier and provider listing of “Other” to “Request Withdraw” so the item will not calculate in the total plan cost. 
  • CMs will add a planned service line for the appropriate code and provider name.
    • The planned service line will include the appropriate DME code without the ZS modifier.
    • The planned service line should list the DME Provider Name (not “Other”).
    • Document in the Comments area that the item was denied by SoonerCare.
 
  • See below for example of planned service line for Member needing adult size pullups (80 per month) that has been denied under their SoonerCare benefit and is now being requested under ADvantage Waiver: 
Last Modified on Feb 08, 2021
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