Obtain service authorization before exceeding max quantity

Services or items that exceed the maximum allowed quantity in the specified timeframe require a service authorization prior to rendering or dispensing. Reference: 7 AAC 120.210(b)(2).

Check SERVICE AUTH flags on fee schedule

The fee schedule marks certain procedure codes in the SERVICE AUTH column (X) to indicate service authorization is required; providers must check the SERVICE AUTH column on the schedule when billing.

Submit acquisition invoice for BY REPORT codes

When a code's rate is listed as BY REPORT, providers must submit the acquisition invoice including all vendor discounts to support reimbursement and rate determination.

• Submit unaltered acquisition invoice showing vendor discounts when billing BY REPORT.

Follow CLAIMS ATTACH / SERVICE AUTH indicators per code

Procedure table rows include administrative flags such as CLAIMS ATTACH REQUIRED and SERVICE AUTH; follow the table indicators and include required claims attachments or obtain service authorization as indicated per code.

• Attach required supporting documentation when CLAIMS ATTACH = X.
• Obtain service authorization when SERVICE AUTH = X.

Include acquisition invoice for BY REPORT items

For items billed 'BY REPORT' providers must submit the acquisition invoice including all vendor discounts with the claim to support payment.

• BY REPORT lines explicitly state: 'SUBMIT ACQUISITION INVOICE INCLUDING ALL VENDOR DISCOUNTS'.

Do not unbundle prohibited pouch/accessory codes

Certain pouch and accessory codes may not be billed separately when provided with related pouch codes; the schedule includes explicit 'MAY NOT BE UNBUNDLED ... IF PROVIDED CONCURRENTLY' statements — do not unbundle these items on claim.

• Do not bill A4376/A4377 separately from A4375 when provided concurrently.
• Do not unbundle A4380/A4382/A4383 from their associated pouch codes where the schedule prohibits it.

BY REPORT items require acquisition invoice submission

Several items (e.g., full-length surgical stockings and selected devices) are reimbursed BY REPORT and require submission of acquisition invoices including all vendor discounts for payment; follow the BY REPORT invoice instructions on the line.

• When RATE = BY REPORT, submit acquisition invoice including all vendor discounts per line.

Confirm PDAC listing for specified systems

Certain systems must be PDAC approved and listed on the fee schedule (examples: A4458/A4459 and Peristeen system entries); ensure device PDAC listing and fee-schedule presence before billing.

• Confirm PDAC approval and that the system appears on the fee schedule prior to billing.

Review per-code authorization and claims attachment notes

Some individual codes differ in whether they require claims attachments or acquisition invoices; review the procedure line (for example, A4660 shows no service auth/claims attach while A4663 and other devices list CLAIMS ATTACH = X or BY REPORT invoice requirements) and comply accordingly.

• Check per-code 'CLAIMS ATTACH' and 'ADDITIONAL BILLING NOTES' fields for attachment or BY REPORT invoice instructions.

Provide BY REPORT acquisition invoice and vendor discounts

Multiple lines in the schedule state 'BY REPORT — SUBMIT ACQUISITION INVOICE INCLUDING ALL VENDOR DISCOUNTS', indicating providers must supply the acquisition invoice and vendor discounts for BY REPORT reimbursement or replacement-only patient‑owned equipment.

• Provide acquisition invoices and vendor discounts when billing BY REPORT or replacement-only patient‑owned equipment lines.

Obtain prior authorization where SERVICE AUTH = X

The SERVICE AUTH column in the table shows X or blank for many codes; providers must obtain service authorization where indicated (SERVICE AUTH = X) before billing or furnishing services requiring prior authorization.

Attach acquisition invoices for BY REPORT items

Several BY REPORT lines and other entries explicitly require submission of acquisition invoices and vendor discounts when billed BY REPORT; include those documents with claims or authorization requests as specified.

• Attach acquisition invoice showing vendor discounts for BY REPORT codes such as A6215/A6218 and other BY REPORT lines.

Include required claims attachments when indicated

Some codes list 'CLAIMS ATTACH = X' which means supporting documentation must be attached to the claim; follow the CLAIMS ATTACH indicators on the fee schedule for each code.

• When CLAIMS ATTACH = X on the line (e.g., A4663, A4670, certain dressing codes), include the specified supporting documentation with the claim.

Follow WAC + 35% reimbursement and 2-unit/month cap for A6250

A6250 NDC‑listed topical barrier/moisturizer products are reimbursed WAC + 35% and the schedule limits reimbursement to no more than 2 combined units of A6250 per month regardless of product; some A6250 entries also show SERVICE AUTH flags for certain NDCs.

• Bill A6250 NDC products at WAC + 35% as shown on the line.
• Ensure combined A6250 billing does not exceed 2 combined units per month across products.
• Obtain service authorization where the specific A6250 line shows SERVICE AUTH = X.

Supply acquisition invoices for BY REPORT rates (dressings/gauze)

Lines with RATE = BY REPORT (examples include A6215, A6218, A6261 and others) require submission of the acquisition invoice including all vendor discounts for determination of payment; include the invoice when billing.

• Submit unaltered acquisition invoice with vendor discounts for BY REPORT dressing and gauze items.

Obtain service authorization when service auth flags present

Some fee-schedule entries display 'SERVICE AUTH REQUIRED' or 'SERVICE AUTH = X' for specific codes/groups (for example, A6251/A6254 or other grouped lines); obtain prior authorization where these flags appear.

Attach supporting documentation when CLAIMS ATTACH = X

Multiple items list 'CLAIMS ATTACH REQUIRED' or 'CLAIMS ATTACH = X' indicating attachments are required with claims for those codes; providers must include the specified supporting documents on claims.

Comply with combined authorization & BY REPORT documentation requirements

Certain HCPCS lines require both service authorization and claims attachments and many state 'SUBMIT ACQUISITION INVOICE INCLUDING ALL VENDOR DISCOUNTS' for BY REPORT pricing; follow the per-code authorization and documentation instructions.

• For codes listed (e.g., A6502–A6531), obtain service authorization where SERVICE AUTH = X and attach acquisition invoices when RATE = BY REPORT.

Document clinical indication for compression stockings (open venous stasis ulcer)

Compression stocking codes (examples A6513, A6530, A6531) are covered when used in the treatment of an open venous stasis ulcer; ensure clinical documentation supports this indication when requesting authorization or billing.

• Include documentation that the stocking is used to treat an open venous stasis ulcer when filing claims or SA requests for these codes.

Provide acquisition invoice and observe replacement-only BY REPORT rules

Submit the acquisition invoice including all vendor discounts for BY REPORT items per line; replacement‑only language applies on some lines (e.g., PAP and collection supplies) and must be followed.

• For BY REPORT lines, provide acquisition invoice and vendor discounts; observe replacement‑only restrictions where noted.

Obtain prior authorization and include claims attachments where indicated

Certain procedure codes require service authorization (SERVICE AUTH REQUIRED = X) and/or claims attachments; examples include A8001 (service auth required) and A9276 (CGM sensors/transmitters) which have service authorization flags.

• Obtain service authorization for codes showing SERVICE AUTH REQUIRED = X before furnishing the item.

Attach invoices/authorization for A9999 and enteral supplies

A9999 and several enteral supply codes require claims attachment and often require acquisition invoices for BY REPORT pricing; B4035/B4036 also indicate service authorization required — attach invoices/authorization as specified.

• Attach invoices and documentation for A9999 and BY REPORT enteral supplies per the 'BY REPORT' and 'CLAIMS ATTACH' instructions.
• Obtain service authorization for B4035/B4036 when SERVICE AUTH = X.

Pediatric thickener SA required; adult requests need clinical review

Food thickeners (B4100 and specified NDCs) are primarily pediatric; adult requests (age 21+) require case‑by‑case clinical review with documentation of contraindication to standard thickeners, and SA requests/claims must be submitted in ounces per day.

• Submit SA requests and claims in ounces per day (1 oz = 28.35 g).
• Provide documentation of contraindication to standard thickeners for adult (21+) requests.

Include product name and NDC on service authorization requests

Service authorization requests for listed enteral formula products must include the product name and NDC; listed NDCs must be specifically identified on SA requests and claims where required.

• Include product name and NDC on service authorization requests and claims for listed enteral formulas.

Do not bill bundled enteral supplies separately (denial risk)

Do not bill B9998 separately for supplies/accessories that are included in daily enteral supply allowances (B4034, B4035, B4036, B4148); separate billing constitutes unbundling and will be denied per LCD/policy article.

• If unbundling is necessary, obtain prior authorization; otherwise, do not submit separate claims for bundled enteral accessories.

Adhere to per‑timeframe limits and attach docs for canes

Canes (E0100, E0105) are listed with per‑timeframe replacement limits (3Y) and specific rates; follow the per‑code max quantity/timeframe and include claims attachments where the line indicates they are required.

• Adhere to the 3‑year replacement timeframe and per‑code quantity limits when ordering and billing cane codes.

Bill crutch codes with correct modifiers and observe limits

Crutch codes (E0110–E0118) have defined rates, modifiers, maximum quantities, and timeframes (commonly 3Y or specified monthly limits); bill the specific HCPCS code and observe the listed limits and modifiers.

• Confirm the correct modifier and timeframe (e.g., 3Y) and do not exceed max quantity when billing crutch codes.

Apply RR/proration and timeframe rules for walkers

Walkers (E0130–E0149) include RR rental/proration notes, replacement timeframes, and per‑timeframe limits; follow the RR month payment rules (months 1–3 at 100% RR; months 4–13 at 75% RR) and per‑code quantity/timeframe constraints.

• Apply RR proration and months 1–3 / 4–13 payment percentages as listed for rental/purchase codes.
• Observe per‑code timeframe (e.g., 3Y) when replacing walkers.

Bill walker attachments with correct quantities and timeframes

Walker attachments (E0153–E0155) and wheel/seat attachments have specified rates, quantity limits, and timeframes; follow the per‑line unit, max quantity, and replacement intervals when billing.

• Do not exceed the listed max quantities and submit claims within the allowed replacement interval (e.g., 3Y, M) for attachments.

Provide documented height/weight when required

Certain items require documented patient height or weight for authorization/payment (examples: documented height ≥72" for some walker items; documented weight ≥300 lbs for heavy‑duty/wide commode chairs); include these measurements in the record and on authorization requests when required.

• Document and retain patient height (e.g., ≥72 inches) or weight (e.g., ≥300 lbs) as required per code.
• Include documented measurements with SA requests or claims when the fee schedule line specifies the requirement.

Attach acquisition invoice for BY REPORT mobility items

Some mobility items (e.g., E0172, E0181, E0182) are BY REPORT and require submission of acquisition invoice including all vendor discounts; include the invoice when billing these items.

• For E0172/E0181/E0182, attach acquisition invoice and vendor discounts as the line states 'BY REPORT SUBMIT ACQUISITION INVOICE INCLUDING ALL VENDOR DISCOUNTS'.