Lawriter - OAC - 5101:3-10-08 Repair of medical equipment.

5101:3-10-08 Repair of medical equipment.

Wheelchair repairs are not directly reimbursable for consumers residing in a nursing facility (NF) as defined in section 5111.20 of the Revised Code. Such repairs are the responsibility of the NF and reimbursed to the NF through the facility per diem. Wheelchair repairs for residents of an intermediate care facility for the mentally retarded (ICF-MR) as defined in section 5111.20 of the Revised Code are covered through direct reimbursement as provided in this rule. The provisions in this rule do not apply to the repair of resident wheelchairs by nursing facilities.

(A) Durable medical equipment covered under rule 5101:3-10-03 of the Administrative Code and speech generating devices.

(1) Department coverage for repair of medical equipment has been established for major and minor repairs.

(a) "Major repairs" are defined as those repairs for which the combined charges for materials and labor exceed one hundred dollars. Prior authorization is required for major repairs to durable medical equipment. Prior authorization requests must include complete itemization of parts and labor.

(b) "Minor repairs" are defined as those repairs for which the combined charges for materials and labor are one hundred dollars or less. For a maximum of one repair per recipient per one hundred twenty-day period, prior authorization is not required for minor repairs to durable medical equipment. Prior authorization must be obtained for minor repairs in excess of one per recipient per one hundred twenty-day period and for minor repairs within ninety days after the dispensing date of equipment or prior to the expiration of any applicable warranty. Prior authorization requests must include complete itemization of parts and labor.

(c) Providers must submit the appropriate procedure code(s) including modifiers as required for all equipment repair claims submissions and prior authorization requests. For the reimbursement of repairs requiring materials and labor, the appropriate procedure codes must be submitted together on the same claim for the same date of service.

(i) For the reimbursement of repairs or replacement parts without a specific procedure code, use code E1399 modified with the "RP" modifier in combination with labor code E1340 as appropriate.

(ii) For the reimbursement of repairs requiring only the time of a technician, without a specific labor code, use labor code E1340.

(iii) For the reimbursement of repairs or replacement of parts of wheelchairs without a specific procedure code, use code K0108 modified with the "RP" modifier in combination with labor code E1340 as appropriate.

(d) All wheelchair and power operated vehicle (POV) repairs must be billed in accordance with rule 5101:3-10-16 of the Administrative Code.

(2) Unless otherwise specified, a fully completed "Certificate of Medical Necessity/Prescription Repair of Durable Medical Equipment (DME)" form JFS 01904, (4/2009) (appendix A to this rule) is required if the item requiring repair:

(a) Was not paid for by the department; or,

(b) Was originally approved through the department's prior authorization procedure and the repair would substantially change the appearance or function of the item; or,

(3) A written prescription is required if the item requiring repair did not require prior authorization but was paid for by the department and is a minor repair. This documentation must be kept in the consumer's medical record.

(4) "Labor" is defined as the time required by a technician to repair, refurbish, or provide nonroutine service on medical equipment more than ninety days after the dispensing date of that equipment and after the expiration of any applicable warranty.

(5) Requests for prior authorization of repairs (both minor repairs in excess of one per one hundred twenty days and major repairs) must itemize parts and labor separately. Prior-authorized labor will be reimbursed at the lesser of the billed hourly rate or the medicaid maximum rate for labor listed in appendix DD to rule 5101:3-1-60 of the Administrative Code, prorated for periods of less than one hour.

(6) Requests for prior authorization of major repairs for durable medical equipment must specify who owns the equipment, the date of purchase or the approximate age of the equipment, and the applicable warranty period.

(7) No reimbursement may be made for:

(a) Any repairs covered under manufacturer or dealer warranty; or,

(b) Repair of rental equipment covered by the rental payment; or,

(d) Costs associated with postage, pick-up, delivery and set-up or installation.

(8) Reimbursement may be provided for major repair of medical equipment not purchased by the department only if that equipment is determined by the department to be medically necessary, evidence of expiration of warranty is submitted with the "Prior Authorization" request, and the department has not provided reimbursement for repair of duplicate or conflicting equipment in the prior twelve months.

(9) The department will not cover new items when simple repairs are all that are necessary. However, providers shall advise the department when, in their professional opinion, replacement of an item would be more cost-effective than repair.

(10) Repairs of recipient-owned durable medical equipment, other than wheelchairs, are eligible for direct reimbursement for recipients residing in nursing facilities (NFs) or intermediate care facilities for the mentally retarded (ICFs-MR) may be billed to the department. Repairs of all wheelchairs for consumers residing in a nursing facility (NF) are not directly reimbursable by the department. Such repairs are the responsibility of the NF and reimbursed to the NF through the facility per diem. Repairs of wheelchairs for consumers residing in an intermediate care facility for the mentally retarded (ICF-MR) with the exception of minor wheelchair repairs as specified in rule 5101:3-10-16 of the Administrative Code are directly reimbursable by the department.

(11) No charge for labor will be reimbursed for repair or replacement of items identified by an asterisk in rule 5101:3-10-20 of the Administrative Code.

(12) Routine maintenance on equipment owned by the recipient is the responsibility of the recipient or the recipient's caretaker. Routine maintenance is defined as those things described in the equipment owner's manual as routine and necessary to maintain optimum functioning of the equipment, and which do not require a skilled or trained technician to perform.

(B) Hearing aids.

(1) "Major repair of hearing aids" is defined as a repair for which the combined charges for materials and labor exceed one hundred dollars. No more than one major repair may be reimbursed in any three hundred sixty-five-day period. Prior authorization is required for major repairs to hearing aids. Payment for a major repair of a hearing aid includes a warranty described in rule 5101:3-10-11 of the Administrative Code to cover all repairs and all related service calls and follow-up during the warranty period. Charges billed to the department shall not exceed:

(a) The provider's usual and customary combined charges when the provider performs the repairs; or,

(b) One hundred twenty-five per cent of the provider's cost as indicated on the invoice for repair issued to the provider when the provider does not perform the repairs.

(2) "Minor repair of hearing aids" is defined as a repair for which the combined charges for materials and labor is equal to or less than the medicaid maximum for a hearing aid repair listed in rule 5101:3-1-60 of the Administrative Code. No more than one minor repair may be reimbursed in any one hundred twenty day period without prior authorization. Charges billed to the department shall not exceed:

(a) The provider's usual and customary combined charges when the provider performs the repairs; or,

(b) One hundred twenty-five per cent of the provider's cost as indicated on the invoice for repair issued to the provider when the provider does not perform the repairs.

(3) The cost of postage, pick-up, or delivery of a hearing aid is considered a cost of doing business and may not be billed separately.

(4) Routine maintenance of hearing aids is the responsibility of the recipient or the recipient's caretaker. "Routine maintenance of hearing aids" is defined as those things described in the owner's manual as routine and necessary to maintain optimum functioning of the hearing aid, including cleaning and checking.

(5) Requests for prior authorization of repairs (both minor repairs in excess of one every one hundred twenty days and major repairs) must specify the nature of the repair, the date of purchase or the approximate age of the equipment, and previous dates of both major and minor repair services.

(1) In addition to the requirements of paragraphs (A)(2) to (A)(12) of this rule, coverage and claims submission for the repair or replacement of parts for orthotic devices is specifically defined in rule 5101:3-10-20 of the Administrative Code.

(2) In addition to the requirements of paragraphs (A)(2) to (A)(12) of this rule, coverage and claims submission for the repair or replacement of parts for prosthetic devices is specifically defined in rule 5101:3-10-20 of the Administrative Code.

(D) Prior authorization requests for the repair of medical equipment will be considered based on medical necessity. However, cases suggesting malicious damage, neglect, culpable irresponsibility, or wrongful disposition of the medical equipment in question will be investigated and prior authorization may be denied for the repair when the department determines it is unreasonable to make further program payment under the circumstances presented to the department in support of the equipment repair request. Providers will provide any information regarding requests for the repair of medical equipment that the department deems necessary in order to evaluate the repair request.

Ohio Department of Job and Family Services

CERTIFICATE OF MEDICAL NECESSITY/PRESCRIPTION

REPAIR OF DURABLE MEDICAL EQUIPMENT (DME)

See Appendix at

http://www.registerofohio.state.oh.us/pdfs/5101/3/10/5101$3-10-08_PH_FF_A_APP1_20091019_0922.pdf

Effective: 10/29/2009
R.C. 119.032 review dates: 08/13/2009 and 10/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021, 5111.262, 5111.20
Prior Effective Dates: 4/7/77, 12/21/77, 1/1/80, 3/1/84, 10/1/88, 5/15/89, 5/1/90, 12/10/93, 1/1/95, 9/1/02, 10/1/04, 1/13/06, 4/9/09, 7/31/09 (Emer)