Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-13 - DURABLE MEDICAL EQUIPMENT, SUPPLIES, APPLIANCES, PROSTHETICS, ORTHOTICS AND PEDORTHICS › Section 560-X-13-.03 - Method Of Requesting DME, Supplies, Appliances And POP

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A written order
			 or a signed prescription (as defined by the Medicare Program Integrity Manual
			 Chapter 5) signed by the prescriber is required for covered items. An EPSDT or
			 Patient 1st primary physician (PMP) referral may be submitted as an order when
			 written according to practice guidelines and state or federal law and must
			 include the date and signature of the prescriber, the item(s) ordered and the
			 recipient name. For acceptable formats of provider signature, refer to Medicaid
			 Administrative Code, Rule No.
			 560-X-1-.18.
(2) A prescription or order is considered to
			 be outdated by Medicaid when it is presented to the provider or Medicaid's
			 fiscal agent past 90 days from the date it was written.
(3) Medicaid considers a prescription to be
			 valid for the dispensing of supplies for a period of twelve months. After the
			 twelve month period of time, the recipient must be reevaluated by the
			 prescriber to determine medical necessity for continued dispensing of medical
			 supplies.
(4) Certain DME, supplies
			 and appliances require prior authorization by Medicaid. Please refer to Chapter
			 14, DME, of the Medicaid Provider Manual published on Medicaid's website.
			 Repairs or replacement of parts, after the first year the equipment or
			 appliance is issued, require prior authorization unless otherwise specified by
			 Medicaid. A provider's failure to go through the process of obtaining prior
			 authorization for repairs or replacement does not by itself constitute a
			 non-covered service.
(5) Procedures
			 for requesting and dispensing DME, supplies and appliances that require a prior
			 authorization are as follows:
(a) The
			 prescriber must complete and sign a written order or prescription and give to
			 the recipient or sponsor to take to the provider of their choice. The
			 prescriber may also fax the prescription or order to the provider of the
			 recipient's choice.
(b) The
			 provider must submit the following documentation by electronic submission, fax
			 or mail to the Medicaid fiscal agent:
1. the
			 appropriate Alabama Prior Review and Authorization Request Form,
2. the EPSDT or Patient 1st PMP Referral
			 Form, if applicable,
3. all
			 necessary documentation to justify medical necessity, and
4. current prescription or order.
(c) Medicaid or its designee will
			 review the request and assign a status of approved, denied or pending.
1. If the request is approved, the provider
			 will receive an approval letter with the ten-digit prior authorization
			 number.
2. If the request is
			 denied, written notice will be sent to the provider and the recipient
			 indicating the reason(s) for denial. Information giving them their right to
			 appeal is also included in this notice.
3. If the request is placed in pending or
			 conditionally approved status, the prior authorization letter will provide
			 information and a timeframe for submission of the invoice.
(d) All prior authorization requests for DME
			 must be received by the Medicaid fiscal agent within 30 calendar days after
			 equipment is dispensed. All prior authorization requests received beyond the 30
			 calendar days after equipment is dispensed will be denied.
(e) The provider may not bill the recipient
			 for an item for which a prior authorization has been denied due to provider
			 error or the provider's failure to submit the necessary medical documentation
			 for the prior authorization request.