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- UCare Minnesota Provider Manual
Use for any miscellaneous supplies for ostomies in the colon, ileum, abdomen, etc. Used for parts or accessories needed for durable medical equipment that is, replacement of batteries or filter.
Use for supplies that do not fit other more specific miscellaneous supply codes. If billing multiple units of the same product, bill using the correct miscellaneous code modifier and indicate the number of units dispensed. Miscellaneous codes that do not require authorization must have a description in the notes field on the Services tab in MN—ITS. Members who self-administer medications using syringes may receive sharps disposal containers. Bill using A and modifier U3 along with appropriate pricing information as outlined in the Billing Policy section.
Submit a pricing attachment for all claims. Code: E NU Weighted blankets or vests are covered for members who have developmental disabilities, including autism spectrum disorders.
The function of the weighted blankets is to provide proprioception deep pressure , which has a calming effect that allows people with developmental disabilities to interact with their environment. Documentation needs to include relevant diagnoses of the member and evaluation performed by an occupational therapist that justifies medical necessity. Skin care products classified as drugs may be covered under the following circumstances:.
The following items are defined as drugs and may be covered only as described in the two bullet points under Topical Products defined as Drugs:. This is not an inclusive list. Not all products that fit into one of the following categories are covered.
Topical products not defined as drugs : Lubricants for ostomy members, non-legend sterile saline irrigation solutions, skin barriers and other topical products that do not contain active ingredients and are not classified as drugs may be billed with the appropriate HCPCS code.
These items require a written order from the physician that includes the exact description of the product to be dispensed, the amount needed and the length of time needed. The following categories of equipment and supplies are never covered by MHCP:. The following list of items are not typically covered because they meet one of the criteria under Typically Noncovered Services:.
Refer to Noncovered Services in the Billing the Member section for more information on how to execute notifying and billing the member for a noncovered item. Follow the general billing information in the Billing Policy section of the manual. Additional information about billing of specific items can be found in the policy section for those items. An add-on is a noncovered item that can be added to a piece of covered equipment. An upgrade is a piece of equipment with extra, more desirable features that substitutes for a less costly piece of equipment.
MHCP will often cover the upgraded item for members who meet criteria if authorization is obtained. For example, MHCP covers manual hospital beds without authorization for members with positioning needs.
A semi-electric hospital bed would be an upgrade unless the member meets MHCP coverage criteria. If MCHP pays for the equipment, a provider can bill a member for a noncovered add-on. If MHCP makes any payment toward the equipment, the provider cannot bill the member or accept payment on behalf of the member for the difference between the covered equipment and the upgraded equipment.
Refer to Noncovered Services in the Billing the Member section. MHCP will not pay for repairs or maintenance to noncovered add-ons or upgraded equipment. Medical equipment that has features that go beyond what is medically necessary are considered upgrades. Providers may choose to supply upgraded equipment but charge MHCP for the non-upgraded item.
The reason for this may be that the provider chooses to carry only upgraded equipment to reduce the costs of maintaining a broader inventory of models or replacement parts.
An example of an upgrade is a standard hospital bed with a mahogany headboard and footboard rather than a plastic headboard and footboard.
The member may not be billed for the provider-initiated upgrades. If the provider chooses to supply upgraded equipment, the provider chooses to accept the MHCP payment for the non-upgraded item as payment in full.
When billing for a provider-initiated upgraded item, the claim must include only the charge and the HCPCS code for the non-upgraded item.
The HCPCS code for the non-upgraded item must be accompanied by the GL modifier medically unnecessary upgrade provided instead of the standard item, no charge. In the narrative field of the claim, specify the make and model of the item actually furnished, and describe why the item is an upgrade.
If prior authorization is needed for the non-upgraded item, submit the request for the HCPCS code of the non-upgraded item using the GL modifier.
Include all required documentation for the medically necessary non-upgraded item, and specify the make and model of the item that will actually be furnished.
Describe why this item is an upgrade. If repairs are needed to a provider-initiated upgraded item, MHCP will only pay for the repairs that might reasonably be required if the non-upgraded item had been provided unless the upgraded item is now medically necessary.
For example, if a standard hospital bed was ordered and a semi-electric bed was provided as a provider-initiated upgrade, MHCP will pay for repairs to a broken caster, but would not reasonably require repair to a motor.
If the repair would not be reasonably required by the medically necessary item, the provider must repair the upgraded item but cannot bill MHCP or the member for the repairs.
Supplier Documentation The medical supplier must have the following information on file additional details about each requirement can be found under this bulleted list :. Treating practitioners can include: physicians, physician assistants, or advanced practice nurses.
Ordering practitioners must be working within their scope of practice. Specific policies may have different treating practitioners allowed to prescribe, see each policy for specific details. MHCP accepts the following order types according to Medicare guidelines.
New Order A new order is needed in the following circumstances:. General Provisions. Face-to-Face Documentation Providers must maintain written or electronic documentation of face-to-face encounters on file and available to DHS upon request.
Documentation must include:. Documentation of face-to-face encounters may be included in clinical and progress notes and discharge summaries. Ongoing Services Ongoing services are not subject to the face-to-face rule. A face-to-face encounter is only required for new medical equipment, supplies or appliances.
Financial Implications Payment for services can be subject to payment recovery if a timely face-to-face encounter was not documented. S ee the Code of Federal Regulations, title 42, part for more information. Medical records must contain the following information:. DHS may request this information in select cases. The supplier is liable for the dollar amount involved if the information is not received, or does not substantiate medical necessity.
Provide proof of delivery in any of the following methods:. Method 1: Supplier delivers items directly to the member or authorized representative. Method 3: Supplier uses a delivery or shipping service to deliver items. Method 4: Items delivered to an LTC facility on behalf of the member. Suppliers must work with the LTC facility staff to implement inventory control to ensure that:. All services that do not have appropriate proof of delivery from the supplier will be denied and all payments must be returned to DHS.
This includes drugs, supplies used with the DME or prosthetic devices, surgical dressings, urological supplies, or ostomy supplies applied in the hospital including items worn home by the member. Follow these guidelines when dispensing equipment and supplies:. The provider must obtain authorization when required. Refer to General Authorization Criteria and Documentation Requirements to see all general criteria that are required for authorization requests.
Authorization can be requested for any piece of medical equipment, supply, prosthetic, or orthotic that is typically considered a non-covered item.
The item must be medically necessary. Enter this request under the HCPC code specified for the item and submit documentation that demonstrates the item meets all the following criteria:. Also, follow these billing guidelines specific to equipment and supplies when applicable. M innesota S tatutes B. Report this page. Find in Table of Contents:. The editors will have a look at it as soon as possible. Self publishing. Share Embed Flag. TAGS manual coverage provider products ucare determinations guidelines mhcp medicare limited minnesota www.
You also want an ePaper? Limited to medically necessary reconstruction of the nose following accident, injury or surgery. Must meet medical necessity criteria. All Products Must be prior authorized. Limited to coverage where clinical symptoms warrant reduction. Also refer to CMS guidelines for Medicare members. UCare encourages the use of Synagis to protect children who are appropriate candidates.
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