Medicaid of Delaware

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• Accessing Wheelchairs Through Medicaid
  • Wheelchair Purchase
  • Roles and Responsibilities of Team Members
  • Wheelchair Repairs
  • Fee-For-Service Medicaid
  • Medicaid MCO

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Accessing Wheelchairs Through Medicaid*

*Remember to first try to access AT through private insurance if the beneficiary has that type of insurance.

Wheelchair Purchase

The following chart outlines the process for obtaining wheelchairs under the Delaware Medical Assistance Program (Medicaid). The steps progress in a sequence from the time an AT need is identified to when the equipment is provided. This is a process that involves many team members. Their roles and responsibilities are outlined after the chart.

Chart: Obtaining Wheelchairs - Medicaid  PDF   |   Text

Roles and Responsibilities of Team Members

Facilitator*

*The facilitator is the person who drives the process. The person could be the consumer, a family member, a case manager, etc.

The facilitator must first determine whether the AT is likely to meet the definition of medical necessity. If it does, and if the individual has a current Medicaid number, then the next step is to determine whether the consumer is covered under the traditional Medicaid fee for service plan or through a Medicaid MCO.

• Completes the Essential Information Form. Detailed instructions for completing this form are included.
  • Essential Information Form | PDF | Large Print | Text
• You will need:
  • Consumer identification information
  • Consumer support/contact information
  • Insurance information
  • Physician information
  • A prescription.
• Identifies the service provider options based on who is a Medicaid provider, who provides services to the MCO (s) and what providers deliver the type of service needed. The AT Provider section of the Website may assist you with this process.
• Calls the service provider and schedules the evaluation, providing all of the information outlined on the Essential Information Form as well as the specific reason for the evaluation.
• Once an appointment is scheduled, informs the appropriate parties (family members, care staff, etc.) of the appointment. Key informants (such as a primary caregiver or case manager) should attend and participate in the evaluation.
• Arranges for transportation to the evaluation, if necessary.
• Secures a copy of the LMN from the vendor, signifying that the claim submission process for the AT device has been completed.
• If a copy of the LMN is not received within 30 days of the evaluation, contacts the vendor.
• If there has been no action on the claim after 30 days of the submission of the LMN, contacts the appropriate Medicaid office:

  DME Review Team
  (302) 255-9500 or 800-372-2022

  First State Health Plan /Christiana Care
  (302) 302-327-7600 (voice); (302) 302-327-7699 (TDD)

  Diamond State Partners
  (800) 390-6093

Service Provider

• Verifies insurance information provided on the Essential Information Form and schedules the appointment.
• Reviews the intake information and obtains signatures on the assignment of benefits form on the day of the evaluation.
  • Assignment of Benefit Examples | PDF | Large Print | Text
• Requests a copy of the prescription (Rx) for the evaluation from the facilitator. Without an Rx, the service will not be provided.
• Completes the evaluation with input from the facilitator, the consumer, and the caregiver(s).
• Provides the facilitator and the caregiver/consumer with a summary of the recommendations. Recommendations should include information about the specific type of equipment and component(s) needed, the estimated date of delivery, and training that is needed once the equipment is obtained.
• Completes an evaluation report and sends a copy to the facilitator, the physician, the vendor, and the consumer/caregiver.
• Sends information to the physician to support formulation of the LMN.
• Contacts the consumer/ facilitator to schedule an appointment when the equipment is ready to be delivered.
• Adjusts or "fits" the new equipment per the specifications outlined in the assessment.
• Provides information about the care and the operation of the equipment as well as warranties, repairs, and follow up upon delivery.

Vendor

The vendor is a member of the assessment team and is responsible for submitting the documentation related to the medical claim for the equipment to the insurance company. The vendor should be enrolled as a DME provider with Delaware's Medicaid Program. If the consumer is covered under an MCO, the vendor must be a participating provider with that MCO.

• Receives a copy of the Essential Information Form.
• Calls the Medicaid/MCO for authorization once equipment is recommended.
• Contacts the physician to request the LMN if it has not been received.
• Submits all paperwork to Medicaid/MCO.
• Orders the equipment.
• Contacts the facilitator, the service provider, and the caregiver/consumer when the equipment is ready to be delivered.

Physician

• Provides a prescription for the evaluation, equipment and/or services needed.
• Provides LMN to vendor based on results of the evaluation.
• Completes the Medicaid CMN* at such times that repairs/modifications are needed.

*Taken from the Supplies and Durable Medical Equipment Program Provider Manual on the Delaware Medical Assistance Program Website, www.dmap.state.de.us/index.html.

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Wheelchair Repairs

These procedures may vary somewhat when specialized equipment is being prescribed. Equipment that is not generally covered by Medicaid may be covered through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program for children 0-21 years of age. The Medicaid-preferred prescription process for this program is described under Medicaid for Children.

Equipment prescribed by primary care physicians is provided through the managed care facilities with which they are affiliated. Again, the equipment supplier must be one of the MCO's preferred providers. While there are similarities regarding the insurer's relationship with the equipment supplier, the process of obtaining equipment may be quite different from the traditional approach described above. However, the general rules about obtaining a professional evaluation prior to selection of equipment, documentation of medical need, and the physician's prescription still apply.

The procedures differ for traditional Medicaid "fee for service" and Medicaid Managed care plans. Determine which Medicaid plan the user is covered under. Contact the vendor to assist with the repair.

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Fee-For-Service Medicaid

Repairs under $300 do not require a pre-authorization.

Contact the vendors and they will provide the labor and parts needed to complete the repair.

Repairs over $300 require a pre-authorization. In order to get a pre-authorization, a CMN must be completed. The CMN includes following information:

• Patient's name and identification number
• Diagnosis
• Dates of services
• Service codes
• Supplies/equipment provided
• Doctor’s signature.

An LMN is required from the physician.

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Medicaid MCO

The vendor must get prior authorization from the MCO for the repair. To get a pre-authorization, one must have a prescription and an LMN. The facilitator at the MCO reviews these documents prior to approving pre-authorizations.

FYI…An Important Note for Health Care Professionals and Their Patients Prescriptions for routine types of medical equipment, such as walkers and standard manual wheelchairs, may not require special letters or involved documentation. When the need is for more unusual or complex equipment such as motorized wheelchairs with custom seating or electronic communication devices, more detailed technical information (and a special type of teamwork) is required. We know that Medicaid will only purchase equipment if a physician prescribes it. Yet, oftentimes the doctor is much less familiar with the technology's benefits than the therapist or rehabilitation engineer who has recommended the device, or even family members who have witnessed its effectiveness in various environments. Consequently, a team approach is strongly recommended. For instance, the doctor should consult with the patient and/or family members, the professional(s) recommending the equipment (e.g., therapists, rehabilitation engineers, or other clinical diagnosticians), and the intended equipment supplier as well. The result will be a more comprehensive assessment of the patient's needs leading to an appropriate prescription. Claims are processed most efficiently when the doctor incorporates all relevant information into a single document of medical necessity for the prescribed equipment, and forwards the document to the supplier to be written onto or attached to the CMN. In any case, it is important to remain focused on the purpose of documentation. Ideally, it should paint a clear picture of the patient's condition and functional level, and how these things related to medical need for the prescribed equipment.

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