Obtain Prior Approval for Identified DME and Follow NCTracks/Attachment D Process

Prior approval is required for many DME items; items that require prior approval are identified on the Durable Medical Equipment Fee Schedule and in Attachment A. Prior approval is valid only for the time period approved on the CMN/PA form; if extended need is anticipated, submit a new CMN/PA. For items not listed in Attachment A, Section C or the DME fee schedule, submit a request for individual review (use Attachment D or NCTracks); EPSDT cases (beneficiaries under 21) require an EPSDT review via NCTracks but still require prior approval when applicable.

• Submit PA requests and supporting health records to the DHHS Utilization Review Contractor as required (see Subsection 5.2).
• Use NCTracks for prior approval submissions and EPSDT review requests per Attachment D instructions when applicable.

When Changing Suppliers, Send New CMN/PA and Pick-up Ticket; 30-Day Deadline Applies

When transferring rental responsibility to a new supplier, the new provider must obtain a completed, signed CMN/PA and a pick-up ticket from the prior supplier; if the item required PA, send the CMN/PA to the address on the form to obtain a new PA number assigned to the new supplier. Failure to submit the pick-up ticket within 30 calendar days may trigger investigation and possible recoupment.

• New supplier: submit CMN/PA and pick-up slip to secure a new PA number when required.
• Prior supplier: provide a pick-up ticket including provider name, beneficiary name, item, and pick-up date within 30 days.

Follow Section 5.x Procedures for Replacements, Rentals, and Supplier Changes (See Attachments for Details)

Follow the policy's prior approval procedures for replacement, rental termination, changing suppliers, and other administrative actions; the excerpt lists these procedural sections but specific step-by-step authorizations and code-level PA rules are in the full policy attachments.

• Refer to Subsections 5.8–5.11 for servicing/repair, replacement, changing suppliers, and terminating rentals.
• Attachment A and Attachment D contain claim/coding and unlisted-item PA procedures, respectively.

Use Attachment A for Code-Based Prior Authorization and Billing Instructions

Refer to Attachment A (Claims-Related Information) for code-level PA and billing instructions — procedure codes, modifiers, billing units, place of service, and reimbursement rules are specified in Attachment A and must be used when submitting claims.

• Use Attachment A, Section C for HCPCS procedure codes and lifetime expectancies.
• Follow Attachment A tables (Procedure Code(s), Modifiers, Billing Units, Place of Service) when completing claims.

Refer to Attachment A, Section C for HCPCS/Code-Based Requirements

See Attachment A, Section C for the list of HCPCS/procedure codes, established lifetime expectancies, and quantity limits; code lists in Attachment A determine which items require PA and how claims must be coded.

• When requesting an item not listed in Attachment A, use Attachment D / NCTracks to request an individual review.
• Attachment A Section C identifies codes that may require prior authorization and shows lifetime/quantity limits.

Follow Payment Coordination and Disclosure Rules in Sections 6.2–6.4

Follow Sections 6.2–6.4 for rules on seeking other payment sources, accepting payment, and disclosing ownership information when coordinating payment and billing for DME.

• Providers must comply with payment coordination and disclosure requirements in the policy when billing Medicaid.

Follow Attachment A Code Lists — Some Codes May Require Prior Authorization

Attachment A includes Procedure Code(s) and other claims sections that may identify codes requiring prior authorization; providers must follow Attachment A for any code-specific PA requirements and coding conventions.

• Check Attachment A, Section C for codes that carry PA requirements or lifetime/quantity limits.

Align Prior Authorization Requests with Attachment A Coding and Claim Rules

Attachment A and the fee schedule are the authoritative sources for coding and PA rules; prior authorization applicability and claim completion requirements are described in Attachment A and must be followed for correct adjudication.

• Use Attachment A for claim type, ICD-10 coding, procedure codes, modifiers, billing units, and place-of-service guidance.

Request Unlisted DME per Attachment D and NCTracks Procedures

To request coverage for DME or supplies not listed in Attachment A Section C, follow the process in Attachment D (Requesting Unlisted DME) and submit required medical documentation via NCTracks for adults; EPSDT cases follow NCTracks EPSDT review instructions for beneficiaries under 21.

• Submit an unlisted-item PA via NCTracks per Attachment D instructions for adult beneficiaries.
• For beneficiaries under 21, request an EPSDT review using NCTracks as directed in Section 2.2.

EPSDT Cases Still Require Prior Approval — Submit EPSDT Review via NCTracks

Even for EPSDT (beneficiaries under 21), prior approval is required when the item normally requires PA; request EPSDT review via NCTracks and include medical documentation demonstrating the service corrects or ameliorates the condition.

• EPSDT does not waive PA requirements — submit PA/EPSDT review through NCTracks and include supporting documentation.

Obtain CMN/PA for Fee-Schedule Items; PA Valid Only for Approved Timeframe

Prior approval is required for items identified on the DME Fee Schedule; PA is valid for the time period approved on the CMN/PA and reauthorization is required for extended need beyond that period.

• Obtain and keep the CMN/PA form; if needed beyond the approved period, submit a new CMN/PA.

NPWT Requires Prior Approval — Initial ≤6 Months; Monthly Re-approval with Monthly Wound Documentation

NPWT pumps and wound care sets require prior approval; initial approval is for up to six consecutive months and continued coverage re-approvals are granted monthly with monthly wound assessments documented by a licensed professional.

• Provide wound evaluation, measurements, prior therapy attempts, and monthly documentation of wound dimension/characteristic changes for re-approval.

Prior Approval Required for External Insulin Infusion Pumps and Related Components; Include Required Diagnostic and Education Documentation

External insulin infusion pumps (including gray adapters and piston rods) require prior approval; document diagnostic testing (C‑peptide or autoantibody), diabetes education, monitoring plans, and beneficiary/caregiver competency and SMBG frequency per policy criteria.

• Prior approval requires ordering clinician documentation that beneficiary will be monitored and that caregiver/beneficiary is competent and educated in pump use.
• Include C‑peptide or beta-cell autoantibody results and SMBG frequency documentation meeting the specified thresholds.

Document Ordering Clinician Experience, Monitoring, and Duration for Pump and Farrell Valve Prior Approval

Ordering clinicians must document experience with pump therapy, monitoring plans, beneficiary/caregiver competency, completion of comprehensive diabetes education, and expected duration when seeking PA for pumps or the Farrell valve; Farrell valve initial PA is limited to one valve per day for up to six months.

• For Farrell valve PA include starting date, expected duration, and documentation of complicating factors and failed decompression measures.
• For pumps, include monitoring commitments and evidence of beneficiary/caregiver training and SMBG adherence.

PA Required for Fee-Schedule Items; Submit Override Requests with CMN/PA and Justification; WCDs Rental-Only

Items identified on the DME Fee Schedule or Attachment A, Section C require prior approval; WAIVER/override requests (quantity or lifetime expectancy) must include CMN/PA form, type of override requested, and an explanation of medical necessity.

• Submit override PA requests with the usual PA documentation plus explicit override justification as described in Subsection 5.5.
• WCDs are rental-only and initial PA is for three months when criteria are met.

New Supplier Must Submit CMN/PA to Obtain New PA Number When Item Requires PA

When a supplier change requires prior approval, the new supplier must send the completed CMN/PA to the address listed on the form to obtain a new PA number assigned to the new supplier.

• Ensure CMN/PA is completed and submitted to the address on the form if PA was required for the item.

Use Current PA Submission Pathways (NCTracks/Attachments) — Historical Processes Have Changed

Prior approval submission pathways have changed historically; follow current instructions (e.g., NCTracks for unlisted items and pediatric mobility devices) and the updated attachments when submitting PA requests.

• EDS assumed prior approval responsibility for pediatric mobility devices in earlier revisions; use current NCTracks submission processes per attachments.

Step Therapy: NPWT Requires Prior Wound Therapy; No Other Step Therapy Rules in Excerpt

No step therapy rules are specified in this excerpt; for NPWT, a complete wound therapy program must have been considered, ruled out, or tried prior to NPWT application.

• NPWT requires prior conservative wound therapy attempts before initiation (see NPWT documentation/criteria).

CGM Routing: Therapeutic CGMs via Pharmacy; Non‑Therapeutic CGMs via DME (No PA; Documentation Required)

Therapeutic CGMs are covered under the Pharmacy benefit; non-therapeutic CGMs are covered under DME and do not require prior approval but require documentation of meeting specified clinical criteria and scheduled redeterminations.

• Non-therapeutic CGMs: initial criteria include SMBG ≥4x/day and face-to-face encounter within 6 months; first redetermination at 6 months, then annually.
• Therapeutic CGMs billed via Pharmacy benefit — do not submit PA under DME.

Use Diabetic Supply Override Process When Preferred Meter Is Incompatible or Unreliable

An override process exists for diabetic supply manufacturer preference when the preferred meter is incompatible with the beneficiary's insulin pump or produces unreliable results despite education; submit an override PA with medical justification per Subsection 5.5.

• Provider must document incompatibility or inability to obtain reliable results and follow override PA submission requirements.

If Purchased Equipment Lacks Warranty, Request PA for Repairs with Detailed Repair Estimate and CMN/PA Entries

When purchased equipment is not under warranty, providers may request prior approval to perform needed service/repairs by submitting a completed CMN/PA with a repair estimate that breaks down parts and labor; record required CMN/PA block details per policy.

• Include repair estimate with parts and labor hours; enter item HCPCS, item age, prior repairs, and current replacement cost in block 30 of the CMN/PA.
• No charge allowed for pick-up/delivery, assembly, freight, or provider travel.

Document Medical Necessity per Item‑Specific 'Documenting Medical Necessity' Sections

The policy includes dedicated 'Documenting Medical Necessity' subsections for many DME types (e.g., NPWT, insulin pumps, CGMs); providers must follow the item-specific documenting requirements when preparing PA and medical records.

• Submit a letter of medical necessity and health records supporting criteria in Subsection 3.2 with PA requests.
• See item-specific subsections (e.g., 5.3.1 for NPWT, 5.3.2 for insulin pumps) for required clinical documentation.

Maintain Required Records per Sections 7.1–7.3 and Attachment A; Keep CMN/PA, Prescriptions, Delivery and Repair Records

Maintain records and comply with Additional Requirements (Sections 7.1–7.3) and Attachment A; providers must keep prescriptions, original CMN/PA forms, delivery/pick‑up slips, repair/service records, and other documentation specified in Section 7.2.

• Keep the prescription signed by the ordering clinician, original CMN/PA, delivery/pick-up slips signed by beneficiary or designee, and full description of items supplied.
• Provide documentation to Medicaid or its contractors upon request for audits or investigations.

Comply with Section 7.2 Record‑Keeping Requirements

Record keeping requirements are listed in Section 7.2; providers must follow those record‑keeping standards and retain required documents to support medical necessity, claims, servicing, and replacement requests.

• Section 7.2 enumerates specific items to keep on file (prescription, original CMN/PA, orders, descriptions, delivery/pick-up dates, service/repair descriptions).

Follow Sections 7.1–7.3 and Attachment A for Compliance and Record Keeping — Noncompliance Risks Denial

Providers must follow Sections 7.1–7.3 (Compliance, Record Keeping, Coordinating Care) and Attachment A guidance to maintain compliance and claims readiness; failure to meet provider qualifications, record keeping, or compliance may trigger denials or recoupment.

• Maintain documentation to substantiate medical necessity and respond to Medicaid/contractor requests.
• Noncompliance with provider qualifications, record keeping, or policy sections 6.1/7.1/7.2 can lead to denials.

Code and Complete Claims per Attachment A and Attachment C; Use Specified Procedure Codes and Modifiers

Submit claims using the procedure codes and modifiers specified in Attachment A; Attachment C provides claim completion instructions (including place of service, billing units, and reimbursement) and claims must be completed per those attachments to support payment.

• Use Attachment C for completing claims for DME or EN services; include correct procedure codes, modifiers, billing units, and place-of-service as listed in Attachment A.

Document Anticipated Need Duration on Orders to Determine Rental vs Purchase; Submit PA via NCTracks When Required

Document anticipated duration of need (≤6 months vs >6 months) on the provider order — the ordering physician/PA/NP must state anticipated need to determine rental versus purchase; when PA is required, submit via NCTracks as instructed.

• If anticipated need ≤6 months, item is rented; if >6 months, item may be rented or purchased.
• Once rental initiated, later purchase PA will be denied until accrued rental reaches allowable purchase price.

Submit CMN/PA with Health Records and Maintain Face‑to‑Face Encounter Documentation (≤6 Months) and Annual Reviews

Submit the CMN/PA with supporting health records demonstrating the beneficiary meets the specified clinical criteria in Subsection 3.2; maintain a face-to-face encounter documented within six months prior to initiation and perform annual reviews as required.

• Include a letter of medical necessity signed by the prescribing clinician if helpful to support the PA.
• Obtain and document a face-to-face encounter within six months of initiation and re-verify need at least every 12 months for continuing rental/supply needs.

Obtain and Retain Signed CMN/PA Before Billing; For Discharge Items Submit Required Documents via NCTracks When PA Is Required

Keep the completed, signed CMN/PA form on file prior to billing for supplies or rental items; CMN/PA validity generally extends up to 12 consecutive months and must be re‑signed before billing beyond 12 months.

• For discharge items requiring PA, submit prescriber's order and admission history/physical electronically via the NCTracks portal.
• For non-PA discharge items, retain orders and supporting documentation on file.

For Replacement Due to Loss/Theft/Fire/Disaster, Submit Required Supporting Documents with CMN/PA

When requesting replacement due to loss, theft, fire, or disaster, include specific supporting documentation (social worker or case manager letter, police report, fire report, or emergency authority documentation) with the CMN/PA to substantiate replacement eligibility.

• Explain why early replacement is needed on the CMN/PA when request is before usual life expectancy.
• Include the required external documentation appropriate to the event (police report, fire report, social worker letter, or FEMA/NC DEM evidence).

Complete CMN/PA with Required Service/Repair Details (HCPCS, Age, Prior Repairs, Replacement Cost) and Retain Original Records

CMN/PA forms must include service/repair details when applicable: description and HCPCS code of the item, age of the item, number of prior repairs, and current replacement cost (entered in block 30); maintain original CMN/PA, prescriptions, delivery/pick-up slips, and service/repair records.

• When submitting repair PA, provide a repair estimate showing parts and labor breakdown.
• Do not bill for pick-up/delivery/assembly/freight or provider travel time/expenses.

Annual Re‑verification: Signed CMN/PA Required Before Billing Beyond 12 Months

Obtain a signed CMN/PA before billing for services beyond 12 months from the last signed CMN/PA; providers must re-verify continuing need at least every 12 months and have the signed form on file before billing.

• If need continues beyond 12 consecutive months, complete and sign a new CMN/PA before billing further services.

Submit 'Medical Documentation' per Updated CMN/PA Guidance (Replaces Older 'Written Statement')

The policy replaced 'written statement' with 'medical documentation' in CMN/PA completion instructions; providers must submit medical documentation per the updated CMN/PA and attachment guidance when requesting PA or documenting medical necessity.

• Follow current Attachment instructions for CMN/PA completion and provide medical documentation rather than legacy written-statement formats.

Use Current NCTracks/Attachment Submission Pathways for Unlisted Items and Pediatric Mobility PAs

Follow current PA submission pathways (for example, NCTracks) for unlisted items and pediatric mobility devices; historical changes moved some PAs and submission responsibilities — verify current routing in the attachments.

• EDS previously handled pediatric mobility devices; confirm current PA receiver and submit via NCTracks as instructed in Attachment D.

Risk of Denial or Recoupment if PA, Provider Qualifications, or Record‑Keeping Requirements Are Not Met

Absence of required prior approval, failure to meet provider qualifications, or failure to comply with record-keeping and documentation requirements (Sections 6.1, 7.1, 7.2) may result in claim denials, recoupment, or billing investigation.

• Ensure provider qualifications are met and documentation is retained per Sections 6.0–7.3 to avoid denials.
• Claims paid for supplies issued before the date of a required prescription/CMN/PA are subject to recoupment.

Claims May Be Denied if Attachment A/C Coding and Claim Completion Instructions Are Not Followed

Failure to submit correct procedure codes, modifiers, billing units, place of service, or other claims information as specified in Attachment A/C may cause claims to be denied or processed incorrectly; complete claims per Attachments A–C.

• Use Attachment C instructions to complete claims and Attachment A for code/modifier/place-of-service guidance.
• Incorrect or incomplete claims may lead to processing delays or denials.

A Purchase PA Will Be Denied After Rental Is Initiated for the Same Item

If rental has been initiated for an item, a subsequent request for prior approval to purchase that same item will be denied; document anticipated need appropriately to avoid improper rental-to-purchase conflicts.

• Once rental begins, accrue rental payments until the capped purchase price is reached for ownership transfer.

NPWT Denial Triggers: Contraindications and Lack of Required Debridement/Assessment

NPWT may be denied/not covered when contraindications exist (necrotic tissue with eschar without attempted debridement, untreated osteomyelitis near the wound, cancer in the wound, or fistula to organ/body cavity near the wound); document debridement and infection status before PA.

• Ensure debridement and infection evaluation are documented in the health record prior to NPWT requests.

Replacement Pumps Denied if Only Out-of‑Warranty or Discontinued; Provide Repair/Warranty Documentation

Replacement pump requests will be denied if the sole reason is that the pump is out of warranty or no longer manufactured; replacements are covered only when the pump is nonfunctional, cannot be repaired, and warranty has expired (with DME provider documentation).

• Provide DME documentation that pump cannot be repaired and that warranty has expired when requesting replacement.

Do Not Bill for Incontinence/Ostomy/Catheter Supplies Before Obtaining Signed Prescription/CMN/PA — Claims Subject to Recoupment

Claims for incontinence, ostomy, and urinary catheter supplies submitted before obtaining the written, signed, and dated prescription (CMN/PA) are considered not medically necessary and are subject to recoupment; obtain and retain the prescription before billing.

• For supplies, retain a completed CMN/PA signed by provider and prescriber (valid for up to 12 months) before submitting claims.
• Quantity billed must match the quantity documented as medically necessary in the prescription.

Supplier Change: Provide Pick‑Up Ticket Within 30 Days or Risk Investigation and Recoupment

When a supplier change involves rental items, failure to provide a pick-up ticket within 30 calendar days may result in an investigation and possible recoupment; the new provider must obtain the pick-up ticket and a new completed, signed CMN/PA as applicable.

• Prior provider must supply pick-up ticket within 30 days including provider name, beneficiary name, item, and pick-up date.
• New supplier must submit pick-up ticket and CMN/PA to receive new PA and rental payments for remaining balance.

Transfer Coordination: New Provider Must Secure Pick‑Up Ticket and CMN/PA; Capped Rental Balance Carries Over

Coordinate transfers of rental equipment with the prior supplier and prescribing clinician; the new provider must obtain the pick-up ticket and new CMN/PA and ensure allowable capped rental period carries over properly.

• Confirm remaining rental balance and transfer rental payments appropriately when changing suppliers.

Follow Updated PA Processes — Historical Denied‑PA Practices Have Been Revised

Historically denied prior approval handling and operational responsibilities have changed; follow the updated PA processes and attachment instructions (e.g., NCTracks and current attachments) when re-submitting PA requests.

• Review revision history and current attachments to ensure PA submission follows the latest workflow.