Current through Register 1531, September 27, 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.
(E)
Provider
Responsibility. The DME provider who submits a claim to the
MassHealth agency for repair of durable medical equipment is responsible for
(1) ensuring quality of workmanship and
parts;
(2) ensuring that the
repaired equipment is free of defects and in proper working
condition;
(3) ensuring that
repairs are completed within a reasonable time after requests for repair, and
any authorizations required for repair, are received by the provider. Providers
must make alternative arrangements such as using subcontractors if the provider
is unable to repair within a reasonable amount of time. The MassHealth agency
reserves the right to issue additional subregulatory guidance on reasonableness
of repair times for specific DME;
(4) taking advantage of all manufacturer
warranties;
(5) complying with the
requirements of the Wheelchair Lemon Law (M.G.L. c. 93, § 107) and any
other applicable provisions of federal and state laws pertaining to the service
provided;
(6) providing the member
with regular updates regarding the status of the repairs and the expected
delivery date of the equipment being repaired; and
(7) responding in a timely fashion to a
member's complaint regarding the repair of the equipment.
(F)
Coverage for Replacement
Equipment. Coverage for replacement equipment will be provided
only when the existing device or system no longer effectively addresses the
member's medical needs, or if the cumulative cost of the repair exceeds the
cost to replace the equipment.
(G)
Repairs of a Member's Serviceable Backup Power
Wheelchair. MassHealth pays for repairs for a member's serviceable
retired backup power wheelchair in the following instances:
(1) the DME provider must obtain prior
authorization from the MassHealth agency or its designee as a prerequisite for
any repair of a member's serviceable retired backup power wheelchair;
(2) the member's medical complexity prevents
them from being able to use a manual wheelchair or loaner power wheelchair when
the primary mobility system needs repair;
(3) the total cost of the repair of the
serviceable backup power wheelchair does not exceed $1,000.00 per calendar
year, unless the MassHealth agency exercises discretion to approve the total
cost of the repair. The MassHealth agency will review requests exceeding
$1,000.00 on a case-by-case basis;
(4) the MassHealth agency will only pay for
the repair of one serviceable backup power wheelchair per calendar
year;
(5) DME providers must
document the serial number of the repaired serviceable backup power wheelchair
and submit the documentation listed at 130 CMR 409.420(D)(2)(c), (d), and (e);
and
(6) all documentation regarding
the repaired serviceable backup power wheelchair must remain in the member's
file.
