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Waiver and Alternative Care (AC) Programs – Specialized Equipment & Supplies Authorization & Billing Responsibilities

Revised: 03-18-2016

The following is the process for both lead agencies and providers when working together to authorize and provide specialized equipment and supplies through a waiver or the Alternative Care (AC) program.

Lead Agency Responsibilities
MHCP-enrolled Provider Responsibilities

MHCP Responsibilities

Lead Agency Responsibilities

Before authorizing equipment or supplies through a waiver or the AC program, lead agencies must follow these steps:

  • 1. Contact the provider to determine if the item:
  • • Requires a doctor’s order to be covered in the health care industry when the recipient does not have a waiver or AC authorization. If the provider reports that a doctor’s order is needed, direct the recipient to obtain a doctor’s order for the item.
  • • Is covered through the recipient’s Medicare coverage, other insurance payer or Medical Assistance (MA) coverage. To determine if Minnesota Health Care Programs (MHCP) covers or can cover an item, review the following sections of the MHCP Provider Manual:
  • Covered services section of Equipment and Supplies
  • Augmentative Communication Devices section when authorizing Assistive Technology devices using HCPCS T2029 through the Developmental Disabilities (DD) waiver
  • 2. Determine if the waiver or AC program allows the item to be approved on the authorization by reviewing the following policy information for:
  • • BI, CAC, CADI, or DD using the Community-Based Services Manual (CBSM)
  • Specialized Equipment and Supplies
  • Oral Nutritional Products
  • Assistive Technology
  • • EW or AC using the Elderly Waiver (EW) and Alternative Care (AC) Program section of the MHCP Provider Manual
  • 3. Contact their regional resource specialist (RRS) (for disability waivers only) when they have questions, need clarification of policies or are requesting special consideration due to a recipient’s circumstances. Contact the RRS at Lead agencies can also submit policy questions using Aging and Disability Policy Quest.
  • 4. Enter the waiver authorization documenting a specific description of the item(s) you are authorizing on the authorization line and enter the following information about the item(s) in your case notes and summarize in the “DHS Comments” section of the authorization:
  • • Information the provider reports for both 1 and 2 above
  • • A specific description and cost of the items (when authorizing more than one specialized supplies and equipment item)
  • • When applicable, if approving the item based on RRS or policy staff approval, enter the DSD & Aging Policy Quest question number
  • Example of note on authorization: Lift chair – a lift chair is a combination of the chair and the lift mechanism. Medicare and MA (with an approved prior authorization) may pay for the lift mechanism, but not for the chair.

  • • The case manager must note: Cost of chair not covered as lift mechanism covered by other payer
  • • When an item is not covered by other payer(s) (Medicare, TPL or MA), then the case manager must note: Does not meet coverage criteria for MA, Medicare, other payer or TPL
  • Lead agencies must follow the Provider Responsibilities guidelines directly below when submitting claims for services or submitting claims on behalf of the provider.

    MHCP-enrolled Provider Responsibilities

    MHCP-enrolled providers advise the lead agency if a doctor’s order is necessary for other payers or TPL, Medicare or MHCP to cover the item following health care industry standards.

    Providers must follow these steps:

  • 1. Check recipient eligibility using MN–ITS, inquire if any other insurance coverage exists that is not currently reported to MHCP and determine whether the item can be covered by other payers, Medicare, TPL or by MA.
  • • If yes, other coverage exists – find out from the other payer(s) if the item is or can be covered with an authorization. If the other payers or TPL, Medicare or MA does not cover, even with an authorization, keep documents showing you verified with other payer.
  • • If no, other coverage does not exist – Follow directions in the following MHCP Provider Manual sections to determine if MA covers the item with or without an authorization:
  • Medicare and Other insurance (under Billing Policy)
  • Covered Services (under Equipment and Supplies)
  • Augmentative Communication Devices
  • 2. Review authorization or purchase agreement for accuracy
  • 3. Document the items the lead agency requests your agency to provide
  • 4. Dispense the item according to your business policies and procedures
  • 5. Ensure you followed the appropriate processes in number 1 and document in the recipient’s file
  • 6. Submit the claim to MHCP for payment:
  • • Use the 837P Professional claim transaction
  • • Follow MHCP Billing Policy guidelines
  • • Itemize each item or service per service line
  • • Effective January 1, 2016, providers must enter the appropriate modifier for dates of service on or after Jan. 1, 2016, for all waivers except for the DD waiver. The modifier will not be included on the SA.
  • • NU = New when purchasing new equipment or supplies
  • • UE = Used when purchasing used equipment or supplies
  • • RR = Rental of equipment or supplies
  • • RB = Repair of an item or part
  • 7. Enter the description of the item you dispensed in the notes section of the service line (notes on the claim must match notes on the SA).
  • Example of Note on Claim: Lift chair is a combination of the chair and the lift mechanism. Medicare and MA (with an approved prior authorization) may pay for the lift mechanism but not for the chair.

  • • Enter note on claim: Cost of chair not covered as lift mechanism covered by other payer
  • • If the item is not covered by other payer (Medicare, TPL or MA) enter note on claim: Chair and lift mechanism does not meet coverage criteria by Medicare or MA
  • Refer to the MN–ITS Interactive user guide for step-by-step instructions when Completing an 837P Professional claim for Waiver and AC services using MN–ITS Interactive.

    MHCP Responsibilities

    MHCP reviews the claim manually and takes appropriate action within 90 days according to the following guidelines:

  • • If the item is known in the health care industry as being a medical item and the item is to be covered by another payer, Medicare or MA, MHCP will deny the waiver claim
  • • If MA covers the item with an approved authorization as reported in Equipment and Supplies section, MHCP will review for an approved or denied MA prior authorization on file
  • • If MA prior authorization does not exist, MHCP denies the waiver claim
  • • If MA prior authorization exists, MHCP reviews for a basic description of the item on both the waiver or AC claim and SA
  • • If the basic description on the claim and SA do not both identify the item being dispensed, MHCP will deny the claim
  • • If the basic description on the claim and SA match, MHCP will process the claim for payment
  • If more than one item is listed on the same service line of the claim, and any of the items on that service line deny for any of the reasons above, MHCP will deny the entire service line.

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