TO:  DME Providers, Prosthetics & Orthotics (P&O) Providers, Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, and Nursing Homes

The Alabama Medicaid Agency’s Durable Medical Equipment Program will make changes to:

• Reimbursement for BiPAP (E0470, E0471 & E0472)

• Humidifier Reimbursement (E0550,E0561, E0562 and E0565)

Detailed information about each change is provided below. 

BiPAP/Humidifier Reimbursement:

DME Provider(s) that submit Prior Authorizations (PA) on BiPAP devices for dates of service on or after January 1, 2014:

• Will no longer be reimbursed for BiPAP and Humidifier devices billed separately on the same date of service;

• Will no longer be reimbursed for the humidifier as a continuous rental when billed with a BiPAP; 

• Will receive the monthly reimbursement amount for procedure codes E0471 & E0472 of $475.37, totaling $4,753.76 at the end of the ten month capped rental period;

• Will receive a monthly reimbursement amount for procedure code E0470 for $219.68, totaling $2,196.80 at the end of the ten month capped rental period; 
  
  
• Will use (LL) modifier when billing for initial PA approved for initial date of service 01/01/14 and after; (Recertification continues to be required after the initial three month trial period.) 
  
  
• Will continue (with approved recertification) to bill the next six months for BiPAP with (LL) modifier.
  
  
• Will bill with NO modifier for the final month (totaling 10 months capped)  
  
  
• Will no longer use the RR modifier for initial BiPAP PAs submitted on or after January 1, 2014

   

  The monthly payment will include delivery, BiPAP and Humidifier devices, in-service for the caregiver, maintenance, repair and supplies.  Alabama Medicaid will not reimburse separately for procedure codes A7030, A7034, A7037 and A7038 during the BiPAP’s ten month capped rental period. Recertification continues to be required after the initial three months.  If the BiPAP is determined not to be medically necessary (i.e., the criteria are no longer met), the device will be returned to the supplier.

   

  If a recipient already has BiPAP and/or humidifier devices on January 1, 2014:

   

  New PA number(s) will be assigned by HP and new PA letters will be mailed to the DME provider(s) to bill for the remaining capped rental months in 2014.

   

  For these PAs, the provider will continue to include the LL modifier for the next up to six (6) claims and the final claim will be billed with no modifier to capture the 10^th capped rental amount. If the cumulative amount has been reached, no additional claims will be paid.

   

  Therefore, providers are to ensure that recipients, who have current prior authorizations (PAs) for both devices, have both the BiPAP and humidifier prior to January 01, 2014.  These items will be considered as purchased and owned by the recipient.  After January 01, 2014, Alabama Medicaid will only reimburse the provider for needed supplies for these recipients.
  
  

  For initial PAs effective for dates of service on or after January 1, 2014:

   

  Submit the initial PA for the three month trial period with procedure codes E0470, E0471, E0472, with modifier (LL) (RENTAL (APPLD TO PUR)) for three units.  With approved recertification, submit the subsequent PA with two detail lines. The first detail will be for six units with modifier (LL) and the second detail will be for one unit with NO modifier.

   

  Modifiers to be used:

   

  PAs submitted on or after January 1, 2014:

   

  • LL modifier should be included for the initial three month trial period and next six months

   

  • NO modifier for the final month (totaling 10 months capped)

   

  • RA will be used for replacement of machine only, within 8 year period. Replacement has to be prior approved by the Agency as directed by policy. (Max Fee price of $4,330.66 for procedure codes E0471 & E0472 and $1,773.70 for procedure code E0470)
    

   

  REMINDER:

  Requests for Medicaid’s authorization of a replacement BiPAP device will be accepted for review every eight years. A request for replacement of the device submitted within less than eight years which is due to a natural disaster, or an occurrence beyond the recipient’s control, and not the result of misuse, neglect or malicious acts by the user may be considered for approval and payment. The provider must obtain a prior authorization, submit the claim electronically to HP for processing with the appropriate procedure code and Modifier CR and keep all documentation in the recipient file.