Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom MHCP is not the primary payer.

MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.

Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.

Eligible Members

Orthotic devices are covered for all eligible MHCP members.

Covered Services

All Covered Orthotics

An orthotic must be prescribed by an enrolled MHCP provider that meets at least one of the following criteria:

· A physician, physician assistant or advance practice registered nurse who is knowledgeable in orthopedics, physiatry, or vascular surgery

· A physician, physician assistant or advance practice registered nurse in consultation with an orthopedist, physiatrist, or physical therapist

· A podiatrist within the scope of their professional practice

Orthotics for the spine

Codes: L0112-L1499
An orthotic for the spine is considered medically necessary to:

· Facilitate healing of the spine or related soft tissues

· Reduce pain by restricting mobility

· Support weak spinal muscles or a deformed spine

· Treat scoliosis

Orthotics for the spine are covered without authorization when medically necessary with the following exceptions:

· HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is more than $400.

· Repairs to an orthotic require authorization if the submitted charge is more than $400.

Orthotics for the hip

Codes: L1600-L1755, L2040-L2090
An orthotic for the hip is considered medically necessary to:

· Stabilize the hip

· Correct and maintain hip abduction

One orthotic for the hip is covered per calendar year without authorization when medically necessary with the following exceptions:

· HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is more than $400.

· Repairs to an orthotic require authorization if the submitted charge for any line using modifier RB is more than $400.

· Authorization is required for the second or subsequent orthotic for the hip in any calendar year.

Lower limb orthotics

Codes: L1810-L2035, L2106-L2999, L4350-L4631
A lower limb orthotic is considered medically necessary to:

· Treat contractures

· Immobilize a limb to promote healing

· Provide support and stability during ambulation

Four lower limb orthotics (two sets of bilateral orthotics) are covered per calendar year without authorization when medically necessary with the following exceptions:

· HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is more than $400.

· Repairs to an orthotic require authorization if the submitted charge for any line using modifier RB is more than $400.

· Authorization is required for the third or subsequent set of lower limb orthotics in any calendar year.

Upper extremity orthotics

Codes: L3650-L3999
An upper extremity orthotic is considered medically necessary to:

· Immobilize an extremity to promote healing

· Treat contractures

· Provide support and stability during activities of daily living

Four upper extremity orthotics (two sets of bilateral orthotics) are covered per calendar year without authorization when medically necessary with the following exceptions:

· HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is more than $400.

· Repairs to an orthotic require authorization if the submitted charge for any line using modifier RB is more than $400.

· Authorization is required for the third or subsequent set of upper extremity orthotics in any calendar year.

Repairs to orthotic devices

Codes: L4000-L4210
Repairs to orthotic devices are covered without authorization with the following exceptions:

· Repairs to an orthotic require authorization if the submitted charge for any line using modifier RB is more than $400.

· HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is more than $400.

Cranial remolding orthotics

Code: S1040
A cranial remolding orthotic is considered medically necessary for treatment of head deformities associated with:

· Premature birth

· Restrictive intrauterine positioning

· Torticollis

· “Back to Sleep” sleeping positions

Up to two cranial remolding orthotics are covered without authorization for members under age 2. Authorization is required for the third and subsequent cranial remolding orthotic.

Cranial prostheses

Code: A9282

A cranial prosthesis is considered medically necessary for treatment of medical conditions that result in hair loss.

One medical wig is covered per calendar year.

Noncovered Services

· A prosthetic or orthotic device for which Medicare has denied the claim as not medically necessary

· A device whose primary purpose is to serve as a convenience to a person caring for the member

· A device that serves to address social and environmental factors and that does not directly address the member’s physical or mental health

· A device that is supplied to the member by the physician who prescribed the device or by a provider who is an affiliate of the physician who prescribed the device

· Repair costs for a prosthetic or orthotic device that is under warranty

· Repair costs for any rented equipment

· Orthotics when used to prevent injury in a previously uninjured limb

· Orthotics that are to be used only during sports or other leisure activities

· A custom-fabricated orthotic when the member’s needs can be met with a prefabricated orthotic

· Stance control orthotics (L2005)

· Externally powered upper extremity orthotics (L3904)

· Electronic or microprocessor-controlled orthotics, including the Sensor Walk, E-MAG

Refer to information under the Noncovered Services heading in the Billing the Member (Recipient) section of the MHCP Provider Manual to review the conditions required to bill the member.

Authorization

Submit authorization requests through MN–ITS (Authorization Request 278). Fax the MN–ITS response with the required documentation, physician’s orders and appropriate additional information to the medical review agent. Write the MN–ITS Authorization Request number on each page of each document. Review the Authorization section of the MHCP Provider Manual for more information about authorization requests.

Authorization Request

The following codes always require authorization if the submitted charge is more than $400: L0452, L0623, L0624, L0629, L0632, L0634, L0999, L1001, L1499, L2861, L2999, L3677, L3891, L3956, L3999 or L4210.

Authorization is required for quantities over the annual limit for hip, lower limb, upper extremity and cranial orthotics.

Authorization is required for repairs to any orthotic if the submitted charge for any line using modifier RB is more than $400.

· Submit the orthotic base HCPCS code with appropriate modifiers on the first line of the authorization request if a new orthotic is being requested.

· List all add-on items on separate lines on the authorization request. List each item by HCPCS code with appropriate modifiers, quantity and submitted charge.

· If requesting authorization for quantities over the annual limit, document why the additional orthotic is required, and how the requested orthotic meets the recipient’s medical and functional needs.

· If requesting authorization because MHCP does not have a fee schedule rate, include pricing documentation. For prefabricated orthotics, submit an invoice or Manufacturer’s Suggested Retail Price list. For custom-fabricated orthotics, submit documentation of labor (in minutes) and invoices for materials.

· If requesting authorization for repairs, document that the repair can reasonably be expected to delay replacement by at least one year.

· MHCP will not authorize more units per line than are allowed by Medicare’s Medically Unlikely Edits (MUEs). When requesting authorization for bilateral orthotics where more units are required than are allowed by the MUEs, the units must be requested on different lines, with modifiers NU RT and NU LT as appropriate. Documentation must clearly establish that the greater number of units is required.

· When multiple items that are different but require the same miscellaneous code are requested, each item must be listed on a separate line of the authorization request. A unique description of each item must be entered into the model number field for each line. The unique description may be a model number or a narrative description up to 20 characters.

· Each line will be approved or denied, with the allowed dollar amount listed if approved.

Billing

Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of Provider Basics for general billing information.

Bill orthotics using MN–ITS 837P. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices MN–ITS User Manual for claim instructions.

· If the member has Medicare, MHCP will pay only the deductible or coinsurance on any item for which Medicare made payment, regardless of any MHCP authorization.

· Shipping, delivery or set-up costs are included in the MHCP maximum allowable payment and may not be separately billed to MHCP or the member.

· MHCP will not pay claims for more units per line than are allowed by Medicare’s Medically Unlikely Edits (MUEs). When billing for bilateral prosthetics where more units are required than are allowed by the MUEs, the units must be billed on different lines, with modifiers NU RT and NU LT as appropriate.

· When billing labor for repairs, specify the number of units and the rate. Do not bill for setup and delivery, or for service calls that do not involve actual labor time for repairs.

· When billing for items approved on an authorization, submit one claim for all approved lines. Make sure the HCPCS codes, modifiers, and descriptions on the claim match the same information on the authorization.

· Enter the authorization number in the authorization field for each claim line.

· When the model number field is used, do not use the Notes field on the Services tab in MN–ITS. Use the Claim Notes field on the Claim Information tab.

· Submit the usual and customary charge for each line, not the approved amount from the authorization letter.

Definitions

Affiliate: A person that directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, the referring physician or consultant.

Custom-fabricated: Made for a specific patient from his or her individual measurements or pattern, starting with basic materials such as plastic, metal, leather.

Orthotic: A rigid or semi-rigid device that is used for the purpose of supporting a weak or deformed body member or for restricting or eliminating motion in a disease or injured part of the body. Elastic support garments do not meet the definition of an orthotic because they are not rigid or semi-rigid devices. Devices that are not rigid or semi-rigid should be coded A4466.

Physiatrist: A physician who specializes in physical medicine or who possesses specialized knowledge of rehabilitation and who is certified by the American Board of Physical Medicine and Rehabilitation.

Prefabricated: Orthotic items that are not fabricated to an individual’s specifications. They may be adjusted or altered to meet the member’s needs, but are not made specifically for the member. An orthotic that is assembled solely from prefabricated components is considered prefabricated.

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