Steps to Acquire Funding for Assistive Devices for Medicaid Recipients

Steps to Acquire Funding for Assistive Devices for Medicaid Recipients

Medicaid pays for assistive technology listed on the authorized fee schedule under the category of medically necessary durable medical equipment.

Medical necessity means that the device is prescribed by a physician; used to restore or approximate normal function of a missing, malformed, or malfunctioning body part; directly related to a diagnosed medical condition; and expected to improve the user’s ability to function.

Durable medical equipment (DME) means that the device can withstand repeated use; is primarily or customarily used to serve a medical purpose; generally is not useful to an individual in the absence of illness or injury; and is appropriate for use in the home.

The process of submitting a claim for prior approval is as follows:

Get an evaluation supporting medical necessity from a qualified medical professional and gets a medical prescription for the device from a doctor.

Take the prescription to medical equipment supplier that is an enrolled Medicaid DME provider.

The equipment supplier fills out a Medicaid Certificate of Medical Necessity and Prior Approval (CMN/PA) form which includes:

provider’s name, address, and provider number

patient’s name, address, and Medicaid ID #

patient’s diagnoses as it relates to the medical need for the device

patient’s functional status

description of the equipment being prescribed

The equipment supplier sends the CMN/PA form to the doctor for signature and documentation of medical necessity for the equipment prescribed. If prior approval is required, the form is sent to EDS for prior approval and assignment of a prior approval number which enables the supplier to bill Medicaid for the equipment.

If prior approval is denied, the patient may request the supplier submit a new CMN/PA with additional documentation of medical necessity to EDS along with a copy of the denied CMN/PA.

If the request is again denied, the patient can request a hearing at the Division of Medical Assistance. Requests for hearings for DME are made through the DMA hearing office at 919-857-4016.

If the denial is upheld by the Medicaid hearing officer,the patient may request a formal hearing by the Office of Administrative Hearings.

The appeals process applies only to items on the Medicaid fee schedule.

For items not on the Medicaid fee schedule, individuals may request that a particular item be considered for addition to the list of covered equipment by writing to the

Division of Medical Assistance and documenting indications for the equipment. Remember that all equipment must be ordered by a physician. Therefore, a physician’s letter of request for coverage is helpful. The address is Nina Yeager, Director, Division of Medical Assistance, 2517 Mail Service Center, Raleigh, NC 27699-2517.

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