TR593Molina Healthcare, Inc., Durable Medical Equipment DME Presentation

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DME
October 2005
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Agenda

• DME Policy
• Definitions
• Package C
• Rent vs. Purchase
• Prior Authorization
• Items
• PA Procedures
• Claims
• Questions and Answers

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DME Policy

• DME Policy
• DME is defined as equipment that
• can withstand repeated use,
• is primarily and customarily used to serve a
  medical purpose and
• generally is not useful to a member in the
  absence of illness or injury

All DME must be ordered in writing by a physician
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DME Policy

• DME Policy
• Package C
• For Package C members, medical supplies and
  equipment, including prosthetic devices, implants
  and hearing aids are covered when medically
  necessary
• DME for these members is limited to
  2,000.00/year or 5,000.00/lifetime (not
  including eyeglasses)
• Equipment may be leased or purchased depending on
  which option is more cost-efficient

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DME Policy

• DME Policy
• Rent vs. Purchase
• Molina is following the existing IHCP policy in
  regard to the rental or purchase of DME items
• The decision to rent or purchase DME is based on
  the least expensive option for the anticipated
  period of need

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DME Policy

• DME Policy
• Continuity of Care
• Service or item authorizations issued by Health
  Care Excel (HCE) for members in the PCCM program
  will be honored for thirty (30) days
• Service or item authorizations issued by other
  MCOs for members now enrolled with Molina
  Healthcare will be honored for thirty (30 days)

Copies of the previously issued authorizations
will be required
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Prior Authorization

• Prior Authorization
• Beginning 1/1/05, all DME items with a line item
  cost of over 200.00 had required PA
• Effective 11/1/05, line item cost will no longer
  determine what items require authorization

A complete list of the HCPCS codes requiring
Prior Authorization will be available
at www.molinahealthcare.com
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Prior Authorization

• Prior Authorization (contd)
• Examples of items that will require PA are
• Hospital Beds
• Wheelchairs
• Ventilators
• Oxygen
• Patient Lifts
• Customized Equipment

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Prior Authorization

• Prior Authorization (contd)
• PA/Service Requests
• Requests must be submitted on the Molina Service
  Request Form
• Each form must be completed in its entirety
  including
• the appropriate HCPCS codes
• clinical documentation to support the need for
  the requested equipment or supplies
• Requests may be mailed to Molina at the address
  of the form or faxed to our office at
  219-736-8771

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Home Medical Equipment Providers

• Effective August 1, 2006 must be licensed by
  Indiana State Board of Pharmacy.
• Providers must update IHCP profiles with IHCP
• Provide copy of license to EDS Provider
  Enrollment
• Obtain HME Provider Specialty 251
• Current DME Providers enrolled as DME Provider
  Specialty 250
• Must bill using HME Provider Code Set
• May submit claims for both HME and non-HME
  supplies providers if enrolled as provider
  specialty 250 251

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Claims

• Claims
• The claim completion requirements for Molina
  Healthcare are the same as those for the IHCP.
  Detailed information regarding claim completion
  may be found in the IHCP Provider Manual, Chapter
  8, pages 8 150 through 8-174
• Claims may be submitted electronically via WebMD
  or,
• by mail to

Molina Healthcare of Indiana P.O. Box 22717 Long
Beach, CA. 90801
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The Molina Mission

• Molina Healthcare is an innovative health care
  leader providing quality care
• and accessible services in an
  efficient and caring manner
• Core Values
• We strive to be an exemplary organization
• We provide quality service
• We are healthcare innovators and respond
  quickly to change
• We respect each other and value ethical
  business practices
• We are careful in the management of our
  financial resources
• We care about the people we serve.
• This is the
  Molina Way

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www.molinahealthcare.com 1-800-642-4509
450 E. 96th St., Suite 5006 Indianapolis, IN. 46
240 8001 Broadway, Suite 400, Merrillville, IN.
46410