Sec. 10.09.12.06. Prepayment Authorization Requirements

A. Prepayment authorization is required for:

(1) Disposable medical supplies with a charge exceeding $500, except as specified in §B(1) and (4) of this regulation and durable medical equipment on the approved list of items as individual consideration (I/C);

(2) All incontinency pants for recipients 3 through 15 years old in excess of 240 in any 30-day period, and disposable underpads for recipients 3 through 15 years old in excess of 135 in any 30-day period;

(3) All incontinency pants for recipients 16 years old or older in excess of 180 in any 30-day period, and disposable underpads for recipients 16 years old or older in excess of 100 in any 30-day period;

(4) All disposable incontinency pants and all disposable underpads for recipients younger than 3 years old;

(5) Disposable medical supplies and durable medical equipment not on the approved list of items;

(6) Any rental of durable medical equipment after 3 months of rental;

(7) All repairs to purchased durable medical equipment exceeding $500;

(8) Durable medical equipment with a purchase price of $1,000 or more except as specified in §B(1) and (3) of this regulation; and

(9) Medical equipment and supplies not listed on the approved list of items.

B. Prepayment authorization is not required for:

(1) Any disposable medical supplies and durable medical equipment for home kidney dialysis purchased or rented for Medical Assistance recipients;

(2) Prosthetic devices;

(3) Orthotic equipment; and

(4) Enteral and parenteral supplies not exceeding one unit per day.

C. The prescriber shall submit requests for prepayment authorization in writing, when required, using the format and procedures designated by the Department.

D. Prepayment authorization, when required, may be requested via a facsimile machine to expedite hospital, nursing facility, or other medical institutional discharge or in emergency situations approved by the Program. In this case, the facsimile of the completed prepayment authorization form shall be followed by a written request for prepayment authorization using the original of the form, which shall be submitted immediately to the Department. Providers shall call the Program before making a request via facsimile.

E. Except as provided in §G of this regulation, providers shall submit prepayment authorization requests to the Program not later than 30 days following the first date of service.

F. Prepayment authorization is issued when:

(1) Program procedures are met;

(2) The prescriber submits to the Department adequate documentation demonstrating that the service to be authorized is medically necessary; and

(3) A request for supplies or equipment on the list of approved items, or on the list but without a specified maximum Program price, is accompanied by the manufacturer's suggested retail price or an invoice or other documentation of the wholesale cost, whichever is applicable under Regulation .07 of this chapter.

G. Prepayment authorization normally required by the Program is waived when the service is covered and approved by Medicare. However, if the entire or any part of a claim is rejected by Medicare, and the claim is referred to the Program for payment, payment will be made for services covered by the Program only if authorization for those services has been obtained before billing. Non-Medicare claims require prepayment authorization according to §§A-F of this regulation.

H. The Department is not responsible for any reimbursement to a provider for any service provided which requires prepayment authorization unless the authorization has been granted by the Program.