Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part III - Amount, Duration, and Scope of Services › Section 12VAC30-50-165 - Durable medical equipment suitable for use in the home

Current through Register Vol. 40, No. 24, July 15, 2024
A. Definitions. The
				  following words and terms when used in this section shall have the following
				  meanings unless the context clearly indicates otherwise:
"Affirmative contact" means speaking, either face-to-face
					 or by phone, with either the individual or caregiver in order to ascertain that
					 the DME is still needed and appropriate. Such contacts shall be documented in
					 the individual's medical record.
"Certificate of Medical Necessity" or "CMN" means the
					 DMAS-352 form required to be completed and submitted in order for DMAS to
					 provide reimbursement.
"Designated agent" means an entity with whom DMAS has
					 contracted to perform functions such as provider audits and prior
					 authorizations of services.
"DMAS" means the Department of Medical Assistance
					 Services.
"DME provider" means those entities enrolled with DMAS to
					 render DME services.
"Durable medical equipment" or "DME" means medical
					 equipment, supplies, and appliances suitable for use in the home consistent
					 with
					 42 CFR
					 440.70(b)(3) that treat a
					 diagnosed condition or assist the individual with functional
					 limitations.
"Enteral nutrition" refers to any method of feeding that
					 uses the gastrointestinal tract to deliver part or all of an individual's
					 caloric requirements. "Enteral nutrition" may include a routine oral diet, the
					 use of liquid supplements, or delivery of part or all of the daily requirements
					 by use of a tube, which is called tube feeding.
"Expendable supply" means an item that is used and then
					 disposed of.
"Frequency of use" means the rate of use by the individual
					 as documented by the number of times per day, week, or month, as appropriate, a
					 supply is used by the individual. Frequency of use must be recorded on the face
					 of the CMN in such a way that reflects whether a supply is used by the
					 individual on a daily, weekly, or monthly basis. Frequency of use may be
					 documented on the CMN as a range of the rate of use. By way of example and not
					 limitation, the frequency of use of a supply may be expressed as a range, such
					 as four to six adult diapers per day. However, large ranges shall not be
					 acceptable documentation of frequency of use, for example, the range of one to
					 six adult diapers per day shall not be acceptable. The frequency of use
					 provides the justification for the total quantity of supplies ordered on the
					 CMN.
"Functional limitation" means the inability to perform a
					 normal activity.
"Practitioner" means a licensed provider of physician
					 services as defined in
					 42
					 CFR 440.50.
"Prior authorization" or "PA" means the process of
					 approving either by DMAS or its prior authorization contractor for the purposes
					 of DMAS reimbursement for the service for the individual before it is rendered
					 or reimbursed.
"Quantity" means the total number of supplies ordered on a
					 monthly basis as reflected on the CMN. The monthly quantity of supplies ordered
					 for the individual shall be dependent upon the individual's frequency of
					 use.
B. General
				  requirements and conditions.
1.
a.
All medically necessary supplies and equipment shall be
					 covered. Unusual amounts, types, and duration of usage must be authorized by
					 DMAS in accordance with published policies and procedures. When determined to
					 be cost effective by DMAS, payment may be made for rental of the equipment in
					 lieu of purchase.
b. No
				  provider shall have a claim of ownership on DME reimbursed by Virginia Medicaid
				  once it has been delivered to the Medicaid individual. Providers shall only be
				  permitted to recover DME, for example, when DMAS determines that it does not
				  fulfill the required medically necessary purpose as set out in the Certificate
				  of Medical Necessity, when there is an error in the ordering practitioner's
				  CMN, or when the equipment was rented.