Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.420 - Repairs to Durable Medical Equipment

Current through Register 1525, July 5, 2024
(A)
Prescription Requirements
. The MassHealth agency does
			 not require a prescription or a letter of medical necessity for the repair of
			 DME that the MassHealth agency previously determined to be medically necessary
			 for the member. A prescription or LOMN are required if the MassHealth agency
			 has not previously determined the medical necessity of the item requiring
			 repair in order to establish medical necessity for the device.
(B)
Repairs of Purchased Durable
			 Medical Equipment Requiring Removal from the Member
. When
			 member-owned equipment has been determined to be unusable and requires repair,
			 MassHealth will pay for temporary replacement equipment. The provider must
			 attempt to supply, on a rental basis, properly working substitute equipment
			 that is comparable in most respects to the equipment to be repaired. Rental of
			 substitute equipment is covered by MassHealth in accordance with rates
			 established by
			 101 CMR 322.00:
Durable Medical Equipment, Oxygen and Respiratory Therapy
			 Equipment
.
(C)
Repairs of Rented Durable Medical Equipment Requiring Removal from
			 the Member
. When a repair service for rented durable medical
			 equipment requires removing the equipment from the member, the provider must
			 supply the member with properly working substitute equipment that is comparable
			 in most respects to the equipment to be repaired. Providers may continue to
			 bill a rental fee in accordance with rates established by EOHHS at
			 101 CMR 322.00:
Durable Medical Equipment, Oxygen and Respiratory Therapy
			 Equipment
, but no extra rental charge is allowed for this substitute
			 equipment.
(D)
Prior
			 Authorization When Total Repair Exceeds $1,000
. DME providers must
			 submit a prior authorization request for total repairs or modifications that
			 exceed $1,000 per repair. For purposes of calculating total
			 repair/modification, providers must include parts and components, including
			 labor, based on EOHHS's rates established at
			 101 CMR 322.00:
Durable Medical Equipment, Oxygen and Respiratory Therapy
			 Equipment
. For purposes of calculating the total repair/modification,
			 the amount is inclusive of all HCPCS codes that have "No", "Sometimes", and
			 "Yes", in the Prior Authorization Approval column on the DME/OXY Payment and
			 Coverage Guideline Tool.
(1) MassHealth pays
			 for repairs to medically necessary mobility systems, including back-up systems,
			 when either the member's primary or back-up systems are customized, adapted, or
			 modified to the extent that no rental equipment or loaner would be comparable,
			 and the repair is not covered under the warranty (
see
130 CMR 409.413(C), (D), and
			 (E)).
(2) The DME provider must submit the
			 following documentation with the repair prior authorization request:
(a) a completed MassHealth Prior
			 Authorization Request (PA-1) form (if request is submitted on paper);
(b) evidence of MassHealth PA for the item
			 requiring repair or a prescription or letter of medical necessity that meets
			 the requirements of
			 130
			 CMR 409.416 if the MassHealth agency has not
			 yet determined the medical necessity of the durable medical equipment requiring
			 repair;
(c) a description of the
			 customization or modification of the member's mobility systems, if
			 applicable;
(d) an invoice or quote
			 for the repaired or replaced item as applicable;
(e) a work order log with the estimated
			 number of hours the repair will take;
(f) a detailed description of the
			 circumstances that made the repair necessary; and
(g) an explanation as to why the repaired or
			 replaced item is not covered under any warranty.