5101:3-10-16 Wheelchairs.

Wheelchairs, including all parts, options, accessories and repairs, are not directly reimbursable for consumers residing in a nursing facility (NF) as defined in section 5111.20 of the Revised Code. Wheelchairs are the responsibility of the NF and reimbursed to the NF through the facility per diem. Wheelchairs 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 wheelchairs provided to the residents of nursing facilities.

(A) Definitions

(1) "Standard wheelchair" is a wheelchair that would generally satisfy the needs of a pediatric or adult individual, including hemi (low seat wheelchairs); is constructed to withstand normal daily use; has the dimensions specified in paragraph (A)(6) of this rule; and is equipped with standard seat and back, with wheel locks, with fixed, swingaway or detachable armrests, and with fixed, swingaway or detachable footrests.

(a) "Standard manual wheelchair" is a wheelchair that meets the specifications in paragraph (A)(1) and paragraph (A)(3) of this rule.

(b) "Standard power wheelchair" is a wheelchair that meets the specifications in paragraph (A)(1) and paragraph (A)(4) of this rule.

(2) "Specially constructed (SC) wheelchair/specially sized (SS) wheelchair" is a wheelchair that does not meet the dimensions of the standard wheelchair as described in paragraph (A)(6) of this rule; is equipped, at a minimum, with standard seat and back, with wheel locks, and with fixed, swingaway or detachable armrests, and with fixed, swingaway or detachable footrests; and is constructed to generally satisfy the needs of populations which require special features (e.g., extra-wide, amputee, reclining, lightweight, high strength light weight, ultra-lightweight, heavy-duty, and extra heavy-duty wheelchairs).

(a) "Specially constructed wheelchair/specially sized manual wheelchair (SCM/SSM-wheelchair)" is a wheelchair that meets the specifications in paragraph (A)(2) and paragraph (A)(3) of this rule.

(b) "Specially constructed wheelchair/specially sized power wheelchair (SCP/SSP-wheelchair)" is a wheelchair that meets the specifications in paragraphs (A)(2) and (A)(4) of this rule.

(3) "Manual wheelchair" is a wheelchair that is designed and constructed to be manually operated and meets the requirements of either paragraph (A)(1) or (A)(2) of this rule. The term manual wheelchair includes:

(a) Any manual wheelchair that has been (or has been requested to be) converted to a motorized wheelchair with the addition of a power add-on accessory; and

(b) Any manual wheelchair that has been (or has been requested to be) revised with a push-rim activated power assist device.

(4) "Power wheelchair" is a wheelchair that:

(a) Has been originally designed and constructed to be powered by batteries in order to meet the needs of persons physically unable to operate a manual wheelchair;

(b) Meets the requirement of either paragraph (A)(1) or paragraph (A)(2) of this rule; and,

(c) Is not a manual wheelchair that has been converted to a motorized wheelchair with the addition of a power add-on accessory or has been converted to a push-rim wheelchair with the addition of a push-rim activated power assist device.

(5) "Push-rim wheelchair" or a "push-rim activated power assisted wheelchair (PAPAW)" is a wheelchair that has a push-rim activated power assist device added to it.

(6) The dimensions for a standard wheelchair are as follows:

(a) The weight is greater than thirty-six pounds;

(b) The seat height is nineteen inches or greater;

(c) The weight capacity is two hundred and fifty pounds or less;

(d) For adult wheelchairs;

(i) The seat width is fifteen inches to nineteen inches; and

(ii) The seat depth is fifteen inches to nineteen inches;

(e) For pediatric wheelchairs the seat width and/or depth must be fourteen inches or less.

(7) "Consumer" is a medicaid-eligible individual.

(8) "Custom seating system" is a wheelchair seating system which is individually made for a patient using a plaster model of a patient, a computer generated model of the patient (e.g., CAD-CAM technology), or the detailed measurements of the patient to create either:

(a) A molded, contoured, or carved (foam or other suitable material) custom-fabricated seating system that is incorporated into the wheelchair base; or,

(b) A custom seating system made from multiple pre-fabricated components or a combination of custom fabricated materials and pre-fabricated components which have been configured and attached to the wheelchair base or incorporated into a wheelchair seat and/or back in a manner that the wheelchair could not be easily re-adapted for use by another individual.

(9) "Adaptive positioning devices" are components that are attached to a wheelchair to facilitate medically necessary, individual-specific posture control, and functioning and are listed as "adaptive positioning devices" under "Wheelchair Part I or Part II" in appendix A of this rule.

(10) "Personal residence" means the consumer's place of residence, if such residence is not a hospital or long-term care facility.

(11) "Long-term care facility (LTCF)" means a nursing facility (NF) or intermediate care facility for the mentally retarded (ICF-MR) as defined in section 5111.20 of the Revised Code.

(12) "Moderate impairment" means the individual has a moderate impairment of strength and tone which result in an inability to maintain functional or symmetrical postures; and/or flexible scoliosis; and/or flexible kyphosis; and/or dislocated hip with a leg length discrepancy of less than two inches; and/or fixed contractures of the hips/knees that cannot be accommodated by standard components (e.g., footrests, legrests).

(13) "Severe impairment" means the individual has severely abnormal (hyper or hypo) tone that prevents him or her from obtaining or maintaining symmetrical postures, or abnormally fixed curvature of the spine.

(14) "Custom wheelchair" is any wheelchair with a custom seating system as defined in paragraph (A)(8) of this rule.

(B) Prior authorization

(1) Except as set forth in paragraph (C) of this rule, prior authorization pursuant to rule 5101:3-10-06 of the Administrative Code is required for the wheelchair to be covered and reimbursed under medicaid. All requests for authorization for the purchase of a wheelchair must indicate the length of the warranty period and what is covered under the warranty.

(2) Wheelchairs will not be authorized for individuals under the age of one year. Only those wheelchairs that are designed to expand to accommodate the growth of an individual will be considered for authorization for growing children who do not fit into an adult sized wheelchair, unless there is a more cost effective, medically necessary alternative appropriate to meet the individual's need. Additional parts required to grow a wheelchair, that are not included with the purchase of the wheelchair, are eligible for reimbursement by the department, if the cost of the additional parts is less than the cost of a new wheelchair.

(3) Wheelchairs, wheelchair parts and accessories, and wheelchair modifications that are beneficial primarily in allowing the consumer to perform leisure or recreational activities are not considered medically necessary and will not be authorized.

(4) Prior authorization of wheelchairs (inclusive of all parts, options and/or accessories) shall be limited to the wheelchair which has been determined by the department to provide mobility to an individual who is either non-ambulatory or who can ambulate for only a brief period of ambulation, and any self and/or assisted ambulation takes considerable effort and/or causes considerable pain; and who, without the specifically approved wheelchair, would be confined to a sedentary state (i.e., lying or sitting, bed-confined or chair-confined). Any bed-confined or chair-confined individual would be considered confined to a sedentary state.

(5) Certain wheelchair parts, accessories, and/or modifications that are distinctly and separately requested from the original wheelchair request require prior authorization. Refer to rule 5101:3-10-03 of the Administrative Code to determine which codes require prior authorization.

(6) ODJFS may deny prior authorization requests when the required forms have not been fully completed or the required form does not provide sufficient information to establish medical necessity or to determine that the criteria for coverage has been met.

(7) Nursing facilities (NFs) are responsible for wheelchairs, including all parts, options, accessories and repairs, for their residents. A prior authorization request received or approved by the department prior to the effective date of this paragraph of this rule for a wheelchair which has already been dispensed or where actual construction of the wheelchair has been initiated by the provider in association with a prescriber's prescription for a wheelchair will be reimbursed directly to the provider by the department. Coverage and payment requests for wheelchairs that do not meet the above criteria are the responsibility of the NF where the consumer resides.

(C) ODJFS will cover the rental of standard manual, hemi manual and lightweight manual (adult or pediatric) wheelchairs for a period of time not to exceed a maximum of three months without prior authorization. The wheelchair bases eligible for rental are denoted by a double asterisk (**) in appendix A of rule 5101:3-10-03 of the Administrative Code. For the wheelchair rental to be covered:

(1) The wheelchair must be prescribed by a physician; and,

(2) The "Letter of Medical Necessity for Manual Wheelchairs without a Custom Seating System" form (JFS 03414, revised 10/2004) must:

(a) Be completed with sufficient information to support that the wheelchair is medically necessary to provide mobility to an individual who, without the specific wheelchair, would be confined to a sedentary state (e.g., lying or sitting, bed-confined or chair confined) for all but very brief periods of ambulation and to support that any self and/or assisted ambulation takes considerable physical effort and/or causes considerable physical pain;

(b) Be signed by the prescribing physician; and,

(c) Be maintained on file by the wheelchair provider.

(3) Rental wheelchairs are not directly reimbursable by the department for consumers residing in a nursing facility. Such services are the responsibility of the NF and reimbursable through the facility cost report mechanism.

(D) LTCF residents: wheelchair coverage limitations.

(1) Wheelchairs of any type whether manual, power or custom and power operated vehicles (POVs) including all parts, options, and accessories for consumers residing in a nursing facility are not directly reimbursable by the department. Such equipment is the responsibility of the NF and reimbursed to the NF through the facility per diem.

(2) Except as provided for under paragraph (D)(3) of this rule, all standard and specially constructed or specially sized manual wheelchairs without custom seating systems and all standard and specially constructed or specially sized power wheelchairs without custom seating systems, which are necessary for the appropriate care of the residents of an ICF-MR are the responsibility of the facility. Reimbursement of any wheelchairs described in this paragraph is made by the department to the ICF-MR through the cost-report mechanism. Except as provided for under paragraph (D)(3) of this rule, eligible providers of DME services may not bill or be reimbursed by the medicaid program for wheelchairs dispensed to residents of the ICF-MR.

(3) Only custom wheelchairs as defined in paragraph (A)(14) of this rule (i.e., those wheelchairs with a custom seating system as defined in paragraph (A)(8) of this rule) and determined by the department to be medically necessary for the resident, in accordance with paragraph (F) of this rule, are eligible for direct payment to the provider. Wheelchairs and wheelchair parts and accessories, prescribed for ICF-MR residents who do not meet all of the medical necessity criteria listed in paragraph (F) of this rule, are the responsibility of the facility and are reimbursed through the per diem rate calculated under sections 5111.20 to 5111.33 of the Revised Code.

(a) A standard or specially constructed or specially sized manual wheelchair may be authorized for direct reimbursement to an eligible DME provider for a resident of an ICF-MR only if the resident meets the coverage requirements for a custom seating system in accordance with paragraphs (D)(3) and (F) of this rule.

(b) A standard or specially constructed or specially sized power wheelchair may be authorized for direct reimbursement to an eligible DME provider for a resident of an ICF-MR only if the resident meets the coverage requirements for a custom seating system in accordance with paragraphs (D)(3) and (F) of this rule, and also meets the requirements for power wheelchairs in accordance with paragraph (G) of this rule.

(4) Reimbursement of any parts, options and accessories for wheelchairs described in paragraph (D)(2) of this rule is made by the department to the ICF-MR through the cost-reported mechanism.

(5) Parts, options and accessories for the wheelchairs described in paragraph (D)(3) of this rule and meeting the criteria for coverage as set forth in paragraph (D)(3)(a) or (D)(3)(b) are eligible for direct reimbursement to the DME provider.

(E) Personal residencies: Wheelchair coverage and limitations

For a consumer who resides in a personal residence, the following criteria must be met for the authorization of a wheelchair:

(1) For a standard manual or specially constructed/specially sized manual wheelchair without a custom seating system to be covered:

(a) The consumer must be evaluated by a physician, licensed physical therapist or licensed occupational therapist who is fiscally, administratively and contractually independent from the DME provider and receives no form of compensation (monetary or otherwise) from the billing DME provider.

(i) The evaluation must be performed no longer than ninety days prior to the submission of the prior authorization request;

(ii) The results of the evaluation must support the information submitted on the ODJFS required form (JFS 03414, revised 10/2004); and,

(iii) A copy of the dated and signed written evaluation must be maintained by the billing provider. The results of the evaluation must be written, signed and dated by the individual who evaluated the consumer as required in paragraph (E)(1)(a) of this rule. If the evaluator personally reported the results of the evaluation on the ODJFS required "Letter of Medical Necessity for Manual Wheelchairs without a Custom Seating System" form (JFS 03414, revised 10/2004) and signed and dated the form, a copy of the form will be considered the written evaluation.

(b) The wheelchair must be prescribed by a physician who personally performed the evaluation or who has reviewed and agreed with the results of the evaluation of the qualifying physician, physical therapist or occupational therapist, in accordance with paragraph (E)(1)(a) of this rule.

(c) The "Letter of Medical Necessity for Manual Wheelchairs without a Custom Seating System" form (JFS 03414, revised 10/2004) must:

(i) Be completed and submitted, based on the results of the evaluation required in paragraph (E)(1)(a) of this rule, and with sufficient information to support that the specific wheelchair is medically necessary to provide mobility to an individual who, without the specifically prescribed wheelchair, would be confined to a sedentary state (e.g., lying or sitting, bed-confined or chair-confined) for all but very brief periods of ambulation and to support that any self and/or assisted ambulation takes considerable physical effort and/or causes considerable physical pain; and,

(ii) Be signed by the prescribing physician.

(2) For standard power wheelchairs and specially constructed/sized power wheelchairs without a custom seating system to be covered for consumers who reside in (or who will be residing in) a personal residence:

(a) The consumer must meet all the requirements set forth in paragraph (G) of this rule; and,

(b) A visit must be performed in the home (i.e., personal residence) and documented in a written report (see part E of the JFS 03411 form) by a person qualified to determine that the consumer or the consumer's caregiver(s) has(have) the ability to properly maintain the power wheelchair; there is electricity available and easily accessible to maintain power to the batteries; transportation of this wheelchair is available, as necessary; the consumer's home (place of residence) is accessible by the power wheelchair; and there is sufficient space and storage area for the wheelchair or power operated vehicle (POV) to assure that it is protected from the elements. The home will be considered accessible only if the consumer can enter and leave the home by power wheelchair or POV; and, within the home the consumer can enter and leave without assistance the following rooms: living room, kitchen/dining area, the consumer's bedroom (or the room with the consumer's bed) and a bathroom.

(i) Except as provided for in paragraph (E)(2)(b)(iii) of this rule, a power wheelchair or POV will not be authorized if all of the conditions set forth in paragraph (E)(2)(b) of this rule are not met.

(ii) A power operated vehicle will not be authorized if the POV is needed only for outside the home or if, because of its size and/or other features, the vehicle is intended primarily for outside use.

(iii) A power wheelchair or power operated vehicle may still be authorized as long as the written report supports that access to some of the rooms listed in paragraph (E)(2)(b) of this rule are not necessary because special accommodations have been made to meet the consumer's activities of daily living.

(3) For any manual wheelchair with a custom seating system to be covered, the criteria set forth in paragraph (F) of this rule must be met.

(4) For any power wheelchair with a custom seating system to be covered, the criteria set forth in paragraphs (F) and (G) of this rule must be met.

(F) Custom wheelchairs (i.e., wheelchairs with custom seating systems): coverage and limitations.

The following criteria and documentation requirements must be met for authorization of a wheelchair with a custom seating system:

(1) The consumer must be evaluated by a physician who is licensed and board certified as a physiatrist, an orthopedic surgeon, or a neurologist; or by a licensed physical therapist or a licensed occupational therapist. In an ICF-MR, the evaluator also must be fiscally, administratively and contractually independent from the DME provider, and must not receive any form of compensation (monetary or otherwise) from the billing DME provider.

(a) The evaluation must be performed no longer than ninety days prior to the submission of the prior authorization request;

(b) The results of the evaluation must support the information submitted on the "Letter of Medical Necessity for Power Wheelchairs and/or Custom Wheelchairs (i.e., with a Custom Seating System)" form (JFS 03411, revised 10/2004); and,

(c) A copy of the dated and signed written evaluation must be maintained by the billing provider. The evaluation must be written, signed and dated by the individual who evaluated the consumer as required in paragraph (F)(1) of this rule. If the evaluator personally reported the results of the evaluation on the ODJFS required form (JFS 03411, revised 10/2004) and signed and dated the form, a copy of the form would be considered the written evaluation.

(2) The wheelchair must be prescribed by a physician who personally performed the evaluation or who has reviewed and agreed with the results of the evaluation of the qualifying physician, physical therapist or occupational therapist in accordance with paragraph (F)(1) of this rule; and,

(3) The "Letter of Medical Necessity for Power Wheelchairs and/or Custom Wheelchairs (i.e., with a Custom Seating System)" form (JFS 03411, revised 10/2004)" must:

(a) Be completed and submitted based on the results of the evaluation required in paragraph (F)(1) of this rule and with sufficient information to support that the wheelchair is medically necessary to provide mobility to an individual who is either non-ambulatory, or who can ambulate for only very brief periods of ambulation, and any self and/or assisted ambulation takes considerable physical effort and/or causes considerable pain, and who, without the specifically prescribed wheelchair, would be confined to a sedentary state (e.g., lying or sitting, bed-confined or chair-confined); and with sufficient information to support that the consumer meets the criteria set forth in paragraph (F)(4) of this rule; including information that is consistent with the consumer's reported diagnosis(diagnoses), medical history, medical records; current plan of care; and,

(b) Be signed by the prescribing physician.

(4) To support medical necessity for an individually customized wheelchair (i.e., a wheelchair with a custom seating system), the following criteria must also be met and documented:

(a) The consumer must have a moderate impairment as defined in paragraph (A)(12) of this rule or a severe impairment as defined in paragraph (A)(13) of this rule;

(b) The consumer must have:

(i) Moderately to severely abnormal tone that prevents him or her from obtaining or maintaining symmetrical postures, or fixed curvature of the spine, for which a custom seating system is necessary; or,

(ii) Skeletal and/or physical deformities or abnormalities that require a custom seating system.

(c) The addition of a custom seating system to the wheelchair must create a wheelchair that is made to fit the consumer's body and/or positioning needs so specifically that the wheelchair can only be used by the individual for whom it was designed; and,

(d) The consumer's need for prolonged sitting tolerance, postural support to permit functional activities, or pressure reduction cannot be met adequately by a planar type seat, a lap tray and/or a spinal orthotic. To meet this condition, the documentation must explain why a specialized seat, a lap tray and/or a spinal orthotic is not adequate for the consumer, and include a statement of the number of hours per day that the patient is expected to be in the wheelchair. If a custom seating system is being prescribed for a consumer who also requires a spinal orthotic, document why both the seating system and the orthotic are medically necessary for the consumer.

(5) Equipment prescription.

An equipment prescription (see part C of JFS form 03411, revised 10/2004) specifying that the wheelchair and a custom seating system that is medically necessary must be completed. The equipment prescription must be prepared by the same professional that performs the assessment, in conjunction with the prescribing physician, and must be signed by all team members involved in the wheelchair prescription process and by the equipment supplier.

(G) Power wheelchairs and power operated vehicles (POVs): coverage and limitations

For a power wheelchair or a power operated vehicle to be covered, all the requirements specified in this paragraph must be met:

(1) The consumer must be evaluated by a physician, licensed physical therapist or licensed occupational therapist who is fiscally, administratively or contractually independent from the DME provider and receives no form of compensation (monetary or otherwise) from the DME provider billing for the wheelchair.

(a) The evaluation must be performed no longer than ninety days prior to the submission of the prior authorization request;

(b) The results of the evaluation must support the information submitted on the "Letter of Medical Necessity for Power Wheelchairs and/or Custom Wheelchairs (i.e., with a Custom Seating System)" form (JFS 03411, revised 10/2004); and

(c) A copy of the dated and signed written evaluation must be maintained by the billing provider. The results of the evaluation must be written, signed and dated by the individual who evaluated the consumer as required in paragraph (G)(1) of this rule. If the evaluator personally reported the results of the evaluation on the required ODJFS form (see JFS 03411, revised 10/2004) and signed and dated the form, a copy of the form will be considered the written evaluation.

(2) The wheelchair must be prescribed by a physician who personally performed the evaluation or who has reviewed and agreed with the results of the evaluation performed by the qualifying physician, the physical therapist or occupational therapist in accordance with paragraph (G)(1) of this rule.

(3) The "Letter of Medical Necessity for Power Wheelchairs and/or Custom Wheelchairs (i.e., with a Custom Seating System)" form (JFS 03411, revised 10/2004) must:

(a) Be completed and submitted based on the results of the evaluation required in paragraph (G)(1) of this rule, with sufficient information to support that the wheelchair is medically necessary to provide mobility to an individual who, without the specifically prescribed wheelchair, would be bed-confined or chair-confined; with sufficient information to support that the consumer meets the criteria set forth in paragraph (G)(4) of this rule; and with information that is consistent with the consumer's reported diagnosis (diagnoses), medical history, medical records, or current plan of care;

(b) Include the consumer's diagnosis (diagnoses) and the estimate of expected hours of use per day; and,

(c) Be signed by the prescribing physician.

(4) Except as provided for in paragraph (G)(6) of this rule, the following criteria must be met and documented to establish medical necessity:

(a) The consumer is totally non-ambulatory and has severe weakness of the upper and lower extremities due to an orthopedic, neurological or muscular condition;

(b) The consumer has no physical ability to operate a manual wheelchair;

(c) The consumer has both the physical and mental ability to safely operate a power wheelchair. Provide documentation addressing head control, upper extremity functioning, joy stick control steering, directionality-steering skill, visual/spatial perception, safety, mobility skills in power wheelchair operation;

(d) The consumer is dependent upon a power wheelchair for functional activities, or there is a significant delay in the acquisition of independence in functional activities that can be positively impacted by a power wheelchair. Document functional status describing how the power wheelchair will allow the consumer to be independent in mobility and allow substantial improvement in achieving independence in one or more of the following functional activities (include a description of how a power wheelchair will increase the consumer's ability to perform these functional activities):

(i) Bathing;

(ii) Grooming;

(iii) Toileting/toilet hygiene;

(iv) Meal preparation;

(v) Housekeeping;

(vi) Laundry;

(vii) Telephone use;

(viii) Medication management;

(ix) Finance management;

(x) Transfers;

(xi) Use and care of equipment; or,

(xii) Activities for which the power wheelchair facilitates independent functioning while in school or work.

(5) When applicable, the following additional criteria must also be met:

(a) For consumers residing in a personal residence, a power wheelchair will be covered only if the criteria set forth in paragraphs (E)(2)(b) to (E)(2)(b)(iii) of this rule are met;

(b) For consumers residing in an ICF-MR, the power wheelchair will be covered only if the criteria set forth in paragraph (F) of this rule are met; and,

(c) Power operated vehicles will only be covered for consumers residing in a personal residence and only if the criteria set forth in paragraphs (E)(2)(b)(i) to (E)(2)(b)(iii) of this rule are met.

(6) The department may determine that coverage of a power wheelchair is necessary under the following circumstances:

(a) The consumer has severe weakness of the upper and lower extremities due to an orthopedic, neurological or muscular condition but is not totally non-ambulatory; and meets the criteria set forth in paragraphs (G)(4)(b) to (G)(4)(d) of this rule; and meets the criteria set forth in paragraph (G)(5) of this rule, as applicable; and meets the criteria for limited ambulation as set forth in paragraph (B)(4) of this rule; or,

(b) The consumer does not meet the criteria set forth in paragraph (G)(4)(b) of this rule, but has limited ability to operate a manual wheelchair; and the consumer meets the criteria set forth in paragraphs (G)(4)(a), (G)(4)(c), and (G)(4)(d) of this rule; and, as applicable, the consumer meets the criteria set forth in paragraph (G)(5) of this rule.

(H) Duplicate equipment.

Medicaid reimbursement is not available for the purchase of more than one wheelchair for current use by a consumer (see paragraph (G) of rule 5101:3-10-05 of the Administrative Code). A wheelchair will not be authorized if the consumer is in possession of a wheelchair or any other equipment, regardless of payer source, which serves the same or similar purpose.

(I) Provider responsibility.

(1) The cost of any changes or modifications of a specially constructed/specially sized wheelchair, a custom seating system, or adaptive positioning devices purchased by the department, which are found to be necessary within the first ninety days following dispensing, must be borne in full by the provider.

(2) Wheelchair authorizations are specific as to manufacturer/make and model, parts, accessories, adaptive positioning devices, modular components, and custom-molded seating. Providers may only bill the department for the specific wheelchair and manufacturer/make and model, parts, accessories, adaptive positioning devices and custom-molded seating that are authorized and subsequently dispensed to the consumer.

(J) Repair and replacement.

(1) Medicaid reimbursement for repairs is limited to one wheelchair per consumer. Payment for loaner wheelchairs, in addition to reimbursement for repairs, is not covered. Repairs for multiple wheelchairs will not be authorized, regardless of the payer source of the wheelchairs. To be eligible for coverage for repairs, the wheelchair must have been determined by the department to be medically necessary, except as provided for in paragraph (J)(7) of this rule. (See rule 5101:3-10-08 of the Administrative Code regarding reimbursement for repairs.)

(2) For NFs and ICFs-MR the cost of wheelchair maintenance and minor repairs is reimbursed through the per diem rate calculated under sections 5111.20 to 5111.33 of the Revised Code and as specified in rules 5101:3-3-19 and 5101:3-3-19.1 of the Administrative Code.

(3) For residents of ICFs-MR direct medicaid reimbursement for repairs is limited to the following "major repairs" as defined in rule 5101:3-10-08 of the Administrative Code.

(a) Major repair of a wheelchair which would be eligible for direct purchase (i.e., only major repairs for custom wheelchairs) in accordance with this rule and is owned by an eligible consumer; and,

(b) Major repairs/replacement of custom seating systems purchased by the department.

(4) Direct reimbursement is limited to a maximum of one wheelchair in five years per consumer. However, if the consumer's condition changes and warrants new or different equipment within the five-year period, the department may authorize new or replacement equipment. Appropriate medical necessity documentation must be submitted when prior authorization is requested for new or different equipment within the five-year period. (See paragraph (B)(2) of this rule regarding growing wheelchairs.)

(5) The replacement of any type of wheelchair, replacement of any custom seating system, or the replacement of adaptive positioning devices will only be prior authorized when medically necessary, regardless of the age of the current equipment, and only when modification or repair of the current equipment is judged to be not cost effective by ODJFS. A request for authorization for replacement of a consumer-owned wheelchair must meet all the requirements of this rule for the type of chair being requested.

(6) A description, model number, manufacturer serial number, date of purchase, and the condition of a consumer's current equipment must be specified on a request for authorization of additional or replacement equipment. (See paragraph (G) of rule 5101:3-10-05 of the Administrative Code regarding duplicate and conflicting equipment.)

(7) A current prescription must be submitted with a request for authorization of a repair when the department did not authorize the purchase of the wheelchair. In this case, a current prescription and documentation of medical necessity must be submitted with the initial request for repair. If the wheelchair is determined to be medically necessary and the repair is authorized, subsequent repairs may be authorized without the submission of a current prescription and documentation of medical necessity.

(8) For a consumer who resides in a personal residence, reimbursement may be authorized for the repair of a consumer-owned wheelchair that is not eligible for purchase in accordance with this rule, if it is determined that the wheelchair meets the seating/wheeled mobility needs of the consumer and it would be more cost effective for the department to authorize the repair rather than the replacement of the wheelchair. Authorization for the repair of a wheelchair does not necessarily indicate that the wheelchair would be authorized for purchase. Replacement of any consumer-owned wheelchair will be authorized in accordance with this rule.

(9) When requesting prior authorization (PA) for a major wheelchair repair service requiring the replacement/repair of wheelchair parts or accessories on or after the effective date of this rule, the process set forth in this paragraph will apply.

(a) Providers must itemize in the request for PA all the parts/accessories in need of repair or replacement using the procedure codes listed in part I or part II of the "Wheelchair" section of appendix A of rule 5101:3-10-03 of the Administrative Code with the modifier RP. If the part does not have a specific procedure code listed in appendix A of this rule, use K0108 modified by the modifier RP and provide a description of the part(s). The RP modifier attached to a wheelchair procedure code indicates that the item described by the code is to be repaired or replaced as part of the major wheelchair repair service.

(b) Providers must itemize in the request for PA the labor services associated with the major wheelchair repair services using the labor code E1340. The PA request should state the estimated labor time. .

(c) Under the prior authorization process, ODJFS will continue to issue the repair and labor codes for wheelchair repair services as listed in appendix A of rule 5101:3-10-03 of the Administrative Code. Both the repair/replacement part(s) component and the labor component of any major wheelchair repair will be bundled into the all-inclusive major wheelchair repair codes. When deemed appropriate, ODJFS may separately authorize any of the codes listed in "Wheelchairs: Part I" of appendix A of this rule, if no additional labor, parts, or accessories are being requested.

(10) Providers must continue to submit claims, and be paid, for both the repair/replacement part(s) and the labor components as an all-inclusive major or minor wheelchair repair service using the wheelchair repair and labor codes specified in appendix A of rule 5101:3-10-03 of the Administrative Code. The procedure codes/modifiers for claims submitted for major repair services must match the codes issued in the prior authorization approval issued by the department.

(K) Valid wheelchair modifiers.

(1) The following modifiers are valid for wheelchair services:

(a) RR - short term rental; or,

(b) RP - repair and/or replacement of part(s) or labor for a major repair.

(2) The appropriate modifier, as listed in paragraph (K)(1) of this rule, must be added to the procedure when requesting authorization for payment for wheelchair rentals or major repair services.

(3) Codes and modifiers submitted on the claim must match the codes and modifiers issued in the prior authorization approval letter.

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 , 5111.262 , 5111.20
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/1/80, 3/1/84, 5/1/90, 12/30/91, 7/1/94, 8/1/95, 8/1/97, 4/1/98, 10/1/04, 4/1/06, 7/31/09 (Emer)