Alerts

Durable Medical Equipment (DME) Program Changes - Revised

8/4/2020

PDF Version

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 CPAP (E0601)

·      Humidifier Reimbursement (E0561, E0562)

·      Mask Reimbursement (A7030, A7032, A7035)

 

CPAP/Humidifier/Mask Reimbursement

DME Provider(s) that submit prior authorizations (PAs) for dates of service on or after March 6, 2020 for CPAP devices:

·      Will be reimbursed for CPAP, humidifier devices, and masks separately when billed on the same date of service.

·      Will be reimbursed for the humidifier as a rent to capped purchase when billed with a CPAP.

·      Will be reimbursed a separate purchase price for masks when billed on the same date of              service. Annual limitations apply.

·      Will be reimbursed the published Medicare rate that is effective March 6, 2020.

Providers may resubmit claims with prior authorizations approved for dates of service March 6, 2020 and after. Providers should bill 3 months rental with an LL modifier. The final purchase payment should be billed without a modifier which will then be considered a capped purchase.

Billable Modifiers to be used for CPAP and Humidifier:

PAs approved for dates of service March 6, 2020 or after

  LL modifier should be included for the initial three-month rental period.

  NO modifier for the final month (totaling 4 months capped).

RA will be used for replacement of machine only, within 8-year period. Replacement must be prior approved by Agency as directed by policy.

 

Reminder: CPAP therapy is covered through the EPSDT Program for children up to the age of 21. Requests for Medicaid’s authorization of a replacement CPAP 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 DXC for processing with the appropriate procedure code and Modifier CR, and keep all documentation in the recipient file. 

 

Policy questions concerning this provider notice should be directed to the DME Program at (334) 242-5050. Questions regarding PA procedures should be directed to Comagine Health at 1-800-949-7536.