Prior authorization required per policy

The policy includes a Prior Approval section and states that Medicaid requires prior approval for certain medical equipment and supplies; items that require prior approval are identified on the Durable Medical Equipment Fee Schedule and prior approval is valid for the period on the CMN/PA form (a new CMN/PA is required for a longer period).

• Items requiring prior approval are listed on the DME Fee Schedule (Medicaid website).
• Prior approval validity is the period approved on the CMN/PA; extend beyond that requires a new CMN/PA.

Prior authorization (not specified here)

This extract contains table-of-contents and attachment references but does not list specific procedure codes or explicit prior authorization code requirements in these chunks; see Attachment A and other policy sections for code-level PA rules.

• Attachment A (Claims-Related Information) includes Procedure Code(s) and related coding guidance (pages referenced).
• Specific CPT/HCPCS codes and PA triggers are in the full policy attachments, not in this excerpt.

Prior authorization (see main policy)

The document references prior approval requirements but this fragment does not include specific code lists or explicit PA rules; providers must refer to the main policy and Attachment A/Section C for the authoritative code and PA requirements.

• Refer to Attachment A, Section C for HCPCS codes, lifetime expectancies, and quantity limits.
• Items not listed in Attachment A Section C or the fee schedule require submission for prior approval review of medical necessity.

Procedure codes and authorization

Attachment A contains the Procedure Code(s) section and related coding guidance which govern claims submission and any prior authorization implications; providers must consult Attachment A (Procedure Code(s), Modifiers, Billing Units) when determining authorization and billing.

• Attachment A subsections include Procedure Code(s), Modifiers, Billing Units, and Place of Service.
• Procedure codes and fee schedule determine which items require prior approval.

Prior authorization (not specified here)

This portion of the document references claims-related attachments and administrative requirements but does not contain explicit prior authorization rules in the provided pages; code-level PA rules are located in the referenced attachments.

• Attachment A and related attachments list claim type, ICD-10-CM/PCS, procedure codes and modifiers.
• Specific PA requirements are detailed elsewhere in the policy and attachments.

Coding and claims impact on prior authorization

Attachment A lists coding and billing subsections (Procedure Codes, Modifiers, Billing Units) that influence prior authorization and claims submission; accurate coding per Attachment A affects PA determinations and claim adjudication.

• Required claim elements (ICD-10-CM, Procedure Codes, Modifiers, Billing Units, Place of Service) are specified in Attachment A.
• Failure to follow Attachment A coding guidance may affect PA and claims outcomes.

Prior authorization (not specified here)

This extract references policy sections and Attachment A but does not state specific prior authorization requirements or affected codes in these chunks; providers must consult the full policy attachments for PA criteria.

• Attachment A: Claims-Related Information is referenced for detailed coding and PA implications.
• Policy implementation and attachments contain the operative PA lists.

Prior authorization not specified in extracted text

The excerpt does not include explicit prior authorization rules or affected CPT/HCPCS codes; prior authorization requirements are likely found in the full policy and Attachment A/Section C.

• Attachment A Section C and the DME fee schedule list HCPCS and PA-related items.
• Providers submitting requests for items not on the list must request prior approval for medical necessity.

Prior authorization (not specified here)

This excerpt lists attachments covering procedure codes and claim information but does not specify prior authorization requirements here; consult Attachment A and the DME fee schedule for explicit PA code lists.

• Attachment A covers Claim Type, ICD-10-CM/PCS, Procedure Codes, Modifiers, Billing Units, Place of Service, Co-payments, and Reimbursement.
• Attachment B and C address provision at discharge and completing claims.

Prior authorization referenced in policy attachments

This segment references implementation/revision information and attachments but does not contain specific prior authorization code lists in this extracted text; providers should review the referenced attachments for PA and claims details.

• Policy implementation and Attachment A are cited as the location for claims and code guidance.
• Specific PA criteria and code lists are in Attachment A/Section C.

Prior authorization — see main policy

The document references policy sections and attachments for claims and coverage; specific prior authorization requirements and affected codes are detailed in the main policy and attachments (not present in this excerpt).

• Attachment C provides instructions for completing claims for DME/EN services.
• Attachment A contains the claims-related elements that inform PA and billing.

Prior authorization (no rules in this excerpt)

This excerpt references policy implementation and claims procedures but does not include specific prior authorization rules or code-level PA requirements in the provided chunks.

• Sections 7.0–8.0 and Attachment A are cited for compliance, record keeping and claims guidance.
• PA specifics are located in other sections/attachments.

Prior approval required for unlisted items

Items not listed in Attachment A Section C or the DME fee schedule must be submitted for prior approval review of medical necessity; for beneficiaries under 21 request an EPSDT review via NCTracks.

• Unlisted items require prior approval review of medical necessity.
• EPSDT review is required for beneficiaries under age 21 (use NCTracks).

Prior approval required for certain DME

Prior approval is required for certain DME and supplies listed on the Durable Medical Equipment Fee Schedule; providers must submit the prior approval request and supporting records to the DHHS Utilization Review Contractor and the CMN/PA governs the approved time period.

• Prior approval requests and supporting health records must be submitted to the DHHS Utilization Review Contractor.
• CMN/PA form indicates approved time period; a new CMN/PA is needed for extended need.

Prior authorization required (oxygen/RAD/CPAP/BiLevel initial approvals timing)

Initial prior approval is required for oxygen, RAD, CPAP, and BiLevel devices; initial oxygen approvals are 12 months for beneficiaries under 21 or those qualifying under Group I, and three months for Group II; initial prior approval for RAD/CPAP/BiLevel is six months.

• Oxygen initial approval: 12 months (under-21 or Group I) with continuation rules; Group II initial approval: 3 months with continuation rules.
• RAD and CPAP/BiLevel initial prior approval period: 6 months.

EPSDT considerations (prior approval exceptions for <21)

For beneficiaries under 21, EPSDT procedures may allow exceptions to policy limitations if services are medically necessary and similarly efficacious alternatives are considered; request an EPSDT review via NCTracks.

• EPSDT exceptions can permit coverage beyond standard policy limits for beneficiaries <21.
• EPSDT review must be requested through NCTracks.

Alternatives required for adults (document alternatives tried)

When requesting oxygen therapy for beneficiaries 21 and older, providers must document that alternative treatments have been tried or deemed clinically ineffective as part of the medical necessity documentation.

• Documentation must state that alternatives were tried/considered or deemed clinically ineffective.
• This is required in addition to qualifying blood gas or pulse oximetry results.

CPAP trial before advanced devices

For coverage of BiLevel with back-up rate or RAD with back-up escalation, CPAP must be considered or trialed first; documentation of an unsuccessful six-month CPAP trial or inability to tolerate CPAP is required for BiLevel coverage in the OSA context.

• BiLevel covered if unsuccessful six-month CPAP trial, inability to tolerate CPAP, or documented special needs by a sleep specialist.
• RAD back-up escalation rules require documented failure of non–back-up device and compliant use data as specified.

TOC indicates provider-facing sections on prior approval and documenting medical necessity

The table of contents and policy structure indicate provider-facing sections on prior approval and documenting medical necessity, but detailed procedural instructions are located in those named subsections rather than in this excerpt.

• See Section 5.2 Prior Approval Requirements and Section 5.3 Documenting Medical Necessity for operational details.
• Providers must supply a letter of medical necessity signed by the prescriber along with the CMN/PA.

Record keeping and claims documentation requirement reference

Providers must maintain records as required by Section 7.2 and coordinate care per Section 7.3; noncompliance with these sections may trigger administrative actions or audits.

• Record Keeping is addressed in Section 7.2 and Coordinating Care in Section 7.3.
• Noncompliance with Sections 7.1–7.3 can result in administrative denial or audit.

Claims submission documentation (Attachment A)

Attachment A contains claims-related information; providers must follow Attachment A guidance when submitting claims for DME respiratory equipment and supplies.

• Attachment A includes Claim Type, ICD-10-CM/PCS, Procedure Codes, Modifiers, Billing Units, Place of Service, Co-payments and Reimbursement.
• Use Attachment C for completing claims for DME or EN services.

Record keeping and care coordination reference (7.1–7.3)

Sections 7.1–7.3 and Attachment A list record keeping, coordinating care, and claims requirements; providers must follow these instructions for documentation and claims submission.

• Follow Attachment A for coding, modifiers, billing units and place-of-service reporting.
• Attachment B addresses provision of DME and supplies on date of discharge.

Record keeping and claim documentation (Attachment A topics)

Attachment A enumerates claims documentation topics (Claim Type; ICD-10-CM/PCS; Procedure Codes; Modifiers; Billing Units; Place of Service; Co-payments; Reimbursement) that providers must follow when preparing claims.

• Required claim elements are specified in Attachment A and must be used on claim submissions.
• Incorrect or missing claim elements per Attachment A may lead to claim denial.

Record keeping referenced (section 7.2)

Record keeping is referenced in Section 7.2; providers must maintain documentation as described there and supply supporting medical records with prior approval requests.

• Prior approval requests must include the prior approval request and all health records supporting that the beneficiary meets specific criteria.
• Medical necessity must be documented by the prescriber (physician, PA, or NP) and may include a signed letter of medical necessity.

Claims documentation topics reference (Attachment A & C)

Attachment A and Attachment C contain claims-related and claim-completion instructions; providers must follow Attachment A coding and Attachment C claim completion procedures when submitting DME/EN claims.

• Attachment C: Completing a Claim for DME or EN Services provides claim completion instructions.
• Attachment A lists codes, modifiers, billing units and place-of-service requirements.

Claims documentation and billing sections (Attachment A)

Providers must follow Attachment A coding, modifiers, billing units, place of service, and reimbursement instructions when submitting DME claims; Attachment A pages are referenced for these specifications.

• Attachment A pages referenced (42–47) contain the claims and coding guidance.
• Failure to adhere to Attachment A may affect reimbursement.

Claims documentation and billing sections (Attachment A list)

Attachment A enumerates the specific fields and sections required on claims; providers should follow Attachment A and B instructions for documentation and claims submission though specific field values are not present in this excerpt.

• Attachment A includes Claim Type, ICD-10-CM/PCS, Procedure Codes, Modifiers, Billing Units, Place of Service, Co-payments, and Reimbursement.
• Attachment B addresses provision of DME and supplies on the date of discharge.

Documentation of anticipated need and prior approval

Providers must document the anticipated duration of need (≤6 months or >6 months) to determine rental versus purchase; once rental is initiated a subsequent prior approval to purchase will be denied.

• Anticipated need ≤6 months = rental; >6 months may be rental or purchase.
• If rental is initiated, later purchase prior approval will be denied; accrued rental payments equal allowed purchase price make item beneficiary property.

Required submission and medical necessity documentation (prior approval to UR Contractor)

Providers must submit a prior approval request and all supporting health records to the DHHS Utilization Review Contractor; medical necessity must be documented by the prescriber via a signed letter of medical necessity and CMN/PA form.

• The prior approval request and all health records supporting that the beneficiary meets specific criteria must be submitted.
• Medical necessity must be documented by the prescriber; a signed letter of medical necessity may be attached to the CMN/PA.

Required documentation for oxygen prior approval (exam within 1 month, flow rate, frequency estimate)

For initial oxygen prior approval, the CMN/PA must include the prescriber's rationale, an exam within one month of therapy start listing diagnosis, the oxygen flow rate, and an estimate of frequency, duration and length of need, plus results of qualifying oxygen analysis (ABG or pulse oximetry).

• Prescriber's documentation must state why oxygen is indicated and include an exam within one month of start listing diagnosis and oxygen flow rate.
• Include results of qualifying oxygen analysis meeting the timing and independence requirements.

Polysomnogram documentation requirements for RAD/CPAP/BiLevel

For initial RAD, CPAP, or BiLevel prior approval, providers must submit a polysomnogram that meets Clinical Coverage Policy 1A-20 requirements; the polysomnogram must report a minimum of two hours recorded sleep without device and include staging, airflow, effort, and oximetry.

• Polysomnogram must be provided according to Clinical Coverage Policy 1A-20 and not performed by a medical equipment provider.
• Minimum of two hours recorded sleep without device and include sleep staging, airflow, respiratory effort, and oximetry.

Timing of qualifying oxygen analysis (inpatient adults: no earlier than 2 calendar days before discharge)

For qualifying oxygen analyses performed inpatient in adults, the reported test must be the one obtained closest to but no earlier than two calendar days before the hospital discharge date; outpatient tests must be during a chronic stable state.

• Inpatient adult test: closest to but no earlier than 2 calendar days prior to discharge.
• Outpatient test: during chronic stable state, not during acute illness or exacerbation.

Contact PHP for benefits/services questions

Contact the beneficiary's Prepaid Health Plan (PHP) for questions about benefits and services available on or after policy implementation; failure to contact the PHP may lead to confusion or denial of services.

• Providers should contact the beneficiary's PHP for benefits/services questions post-implementation.
• Not contacting the PHP may result in service/benefit confusion or denial.

Claims/billing risk (Attachment A/C reference)

Claims that do not follow Attachment A or Attachment C instructions — including missing or incorrect coding, modifiers, billing units, or incomplete claim forms — may be returned or denied; providers must adhere to Attachment A/C specifications.

• Attachment A lists required claim elements; Attachment C provides claim completion instructions.
• Noncompliant claims may be returned or denied.

Attachment A claims risk note

Attachment A includes claims-related instructions and modifier guidance; failure to follow Attachment A instructions when submitting claims may lead to claim denial.

• Attachment A sections include Procedure Codes, Modifiers, Billing Units and Place of Service.
• Use Attachment A pages 42–47 for codes, modifiers, billing units and place-of-service reporting.

Claims submission triggers (denial risk if not following Attachment A)

Claims may be denied if not submitted in accordance with Attachment A (Claim Type, ICD-10-CM/PCS, Procedure Codes, Modifiers, Billing Units); ensure all required fields follow Attachment A specifications.

• Required fields include ICD-10-CM/PCS diagnosis coding, procedure codes, modifiers and billing units.
• Place of Service and reimbursement rules are also defined in Attachment A.

Claims submission accuracy (Attachment A required fields)

Claims-related information and required claim elements are specified in Attachment A; failure to submit correct diagnosis/procedure codes, modifiers, billing units, or place-of-service per Attachment A may trigger claim denials.

• Attachment A lists Claim Type, ICD-10-CM/PCS, Procedure Codes, Modifiers, Billing Units, Place of Service, Co-payments and Reimbursement.
• Ensure claim data completeness to reduce denial risk.

Administrative noncompliance risk (sections 7.1–7.3)

Noncompliance with Sections 7.1 (Compliance), 7.2 (Record Keeping), and 7.3 (Coordinating Care) can result in administrative denials or audits; maintain required documentation and comply with these sections.

• Section 7.2 addresses Record Keeping requirements providers must follow.
• Section 7.1 addresses Compliance obligations that may be audited.

No explicit authorization triggers present in extract

This excerpt contains table-of-contents and attachment references but no explicit authorization triggers or denial criteria; providers must consult the full policy for specific PA triggers and denial criteria.

• PA triggers and denial criteria are documented in the full policy and attachments, not in this extract.
• Refer to Sections 5.0–5.3 and Attachment A/C for operational details.

Prior authorization (no explicit denial triggers in excerpt)

No explicit prior-authorization denial triggers are present in this excerpt; the document lists attachments and claims topics but specific denial rules are located in the detailed criteria sections.

• Specific denial triggers (e.g., failure to meet medical criteria) are in Section 3.0 and related subsections.
• Claims denials for insufficient documentation are covered by Attachment A/C guidance.

No explicit denial triggers present in these chunks

No explicit denial triggers are present in these chunks; the policy fragment primarily lists attachments and table-of-contents entries — see Sections 3.0 and 4.0 for denial criteria.

• Section 4.0 lists general criteria not covered (e.g., beneficiary not eligible, duplicates, experimental).
• Specific not-covered or denial criteria are in later sections.

Claims/coding errors may trigger denials (Attachment A details)

Claims and coding errors — including incorrect codes, missing modifiers, wrong billing units, or incomplete documentation — are detailed as causes for claim denials in Attachment A; providers must ensure coding accuracy.

• Attachment A provides coding, modifiers and billing unit guidance to prevent denials.
• Incorrect claim data per Attachment A may lead to denial or return of claims.

Claims-data related denial triggers

Claims-data related denial triggers are identified in Attachment A (Claim Type, ICD-10-CM/PCS, Procedure Codes, Modifiers, Billing Units, Place of Service); ensure all required data elements match Attachment A requirements to avoid denials.

• Provide accurate ICD-10-CM diagnosis codes and procedure codes per Attachment A.
• Report appropriate modifiers and billing units as specified.

Claim completion errors (Attachment C may cause return/denial)

Claims that do not follow the instructions in Attachment C (Completing a Claim for DME or EN Services) may be returned or denied; complete claims per Attachment C guidance.

• Use Attachment C instructions when completing DME or EN claim forms.
• Incomplete or incorrect claim completion can result in claim return or denial.

Purchase after rental denial risk

A subsequent request for prior approval of purchase will be denied when rental has been initiated on an item; providers must document anticipated need before initiating rental if purchase is intended.

• If anticipated need ≤6 months, item is rented; if >6 months may be rented or purchased but once rental starts purchase PA is denied.
• Accrued rental payments equal to Medicaid allowable purchase price transfer ownership to beneficiary.

General denial triggers (eligibility, coverage criteria, duplication, experimental)

Claims may be denied if the beneficiary does not meet eligibility (Section 2.0), does not meet coverage criteria (Section 3.0), the service duplicates another provider's service, or the service is experimental/investigational.

• Verify beneficiary eligibility and that the requested service meets Section 3.0 criteria before submitting PA or claims.
• Duplicate services or experimental procedures are not covered.

Polysomnogram requirements trigger denials

Claims for RAD, CPAP, or BiLevel devices and related accessories are denied as not medically necessary if required polysomnogram criteria are not met or if polysomnograms are performed by a medical equipment provider.

• Polysomnograms must meet Clinical Coverage Policy 1A-20 requirements and include at least two hours recorded sleep without device.
• Polysomnograms performed by a medical equipment provider are not accepted.

Noncompliance with use requirements may trigger denial at renewal

Failure to document compliant device use (average four hours per 24-hour period) at renewal is a basis for denial as not medically necessary; renewal prior approval for RAD and CPAP/BiLevel requires clinician confirmation of continued use.

• For RAD renewal, obtain statement of compliance declaring average 4 hours/24-hour use no sooner than the fifth month.
• For CPAP/BiLevel renewal, determine continued use and submit treating clinician statement no sooner than month five.

Document medical necessity per policy subsections

Providers must document medical necessity as described in the Documenting Medical Necessity subsections; a signed letter of medical necessity from the prescriber may be submitted with the CMN/PA for every item provided.

• Medical necessity must be documented by the prescriber (physician, PA, or NP) for every item.
• A signed letter of medical necessity may accompany the CMN/PA form.

Maintain records and submit claims per Attachment A guidance

Maintain records per Section 7.2 and submit claims in accordance with Attachment A guidance; record keeping and claims-related documentation are required for compliance and claim adjudication.

• Section 7.2 addresses record keeping requirements providers must follow.
• Attachment A provides the claim submission and coding guidance.

Follow Attachment A for claims submission

Providers must follow Attachment A when submitting claims for DME respiratory equipment and supplies; Attachment A lists required claim elements including Claim Type, ICD-10-CM/PCS, Procedure Codes and Modifiers.

• Use Attachment A pages 42–47 for procedure codes, modifiers, billing units and place-of-service reporting.
• Attachment C contains instructions for completing a claim for DME/EN services.

Maintain records and coordinate care per Sections 7.1–7.3

Providers must maintain records and coordinate care according to Sections 7.1–7.3; these Additional Requirements are referenced throughout the policy and are necessary for compliance and prior approval support.

• Sections 7.1 Compliance, 7.2 Record Keeping and 7.3 Coordinating Care set provider obligations.
• Noncompliance may lead to administrative action.

Use Attachment A for codes, modifiers, and billing units

Use Attachment A (pages 42–47) for codes, modifiers, billing units and place-of-service when submitting DME claims; Attachment A details the claims-related coding and billing information providers must use.

• Attachment A subsections include Procedure Codes, Modifiers, Billing Units and Place of Service.
• Follow Attachment A specifications to reduce claim denials.

Submit claims with required coding, modifiers, billing units, and place-of-service

Submit claims with required diagnosis and procedure coding, appropriate modifiers, authorized billing units, and place-of-service per Attachment A to ensure correct adjudication and reimbursement.

• Report ICD-10-CM diagnosis codes and PCS as required in Attachment A.
• Include appropriate modifiers and billing units specified in Attachment A.

Maintain records per Section 7.2

Maintain records per Section 7.2; the policy references record keeping requirements that providers must follow though detailed lists are in the full policy Section 7.2.

• Section 7.2 covers record keeping obligations for providers supplying DME.
• Keep documentation to support prior approval requests and continued medical necessity.

Follow Attachment A claims-related specifications

Follow Attachment A claims-related specifications when submitting claims (specific fields and codes are contained in Attachment A); providers should reference Attachment A for exact claim formatting and required elements.

• Attachment A lists Claim Type, ICD-10-CM/PCS, Procedure Codes, Modifiers, Billing Units, Place of Service, Co-payments and Reimbursement.
• Use Attachment C to complete DME/EN claims.

Follow Attachment A and B instructions for documentation and claims

Providers should follow Attachment A and B instructions for documentation and claims submission; Attachment B addresses provision of DME and supplies on the date of discharge and Attachment A contains the claims elements.

• Attachment B: Provision of DME and Supplies on the Date of Discharge from Specified Facilities.
• Attachment A: detailed claims-related information.

Follow Attachment A coding, modifiers, billing units and reimbursement instructions

Follow Attachment A coding, modifiers, billing units, place of service, and reimbursement instructions when submitting DME claims; these attachments provide the operative billing rules.

• Attachment A pages 42–47 contain claims and coding guidance.
• Adhere to Attachment A to ensure reimbursement and compliance.

Use Attachment C for completing claims

Use Attachment C for completing claims for DME or Enteral Nutrition services; Attachment C provides the required claim completion instructions referenced in the policy.

• Attachment C: Completing a Claim for DME or EN Services is on page 50.
• Follow Attachment C to avoid claim return or denial.

Follow Attachments A, B and C when billing/providing DME

Providers must follow the instructions in Attachment A, Attachment B, and Attachment C when billing and providing DME/supplies; these attachments collectively define claims, discharge provision, and claim completion requirements.

• Attachment A: Claims-Related Information; Attachment B: Provision on date of discharge; Attachment C: Claim completion.
• Adherence to attachments is required for compliant billing and provision.

Document anticipated need; prior approval for unlisted items; EPSDT for <21

Document the anticipated need duration (≤6 months or >6 months) to determine rental versus purchase and submit prior approval for items not listed in Attachment A Section C; for beneficiaries under 21 request an EPSDT review.

• Anticipated need documentation guides rental vs purchase decisions.
• Unlisted items require PA review; EPSDT review via NCTracks for <21.

Submit CMN/PA with signed LOMN and qualifying ABG/pulse oximetry

Submit a CMN/PA with a signed letter of medical necessity and qualifying ABG or pulse oximetry that meets the timing and independence requirements (initial analysis within one month before approved start date; tests must not be performed by supplier or vested-interest clinicians).

• CMN/PA must include prescriber's rationale and signed letter of medical necessity.
• Qualifying oxygen analysis must meet timing (within one month) and independence rules (not by supplier or vested-interest physician).

Required for initial oxygen prior approval (prescriber rationale, recent exam, flow rate, frequency estimate)

For initial oxygen prior approval the CMN/PA must include prescriber's rationale, documentation of an exam within one month listing diagnosis, the oxygen flow rate, and an estimate of frequency/duration/length of need plus the qualifying oxygen analysis results.

• Include prescriber's statement of why oxygen is indicated and exam within one month listing diagnosis and flow rate.
• Provide estimate of frequency, duration and length of need and ABG or pulse oximetry results.

Required for initial RAD/CPAP/BiLevel prior approval (polysomnogram rules)

For initial RAD, CPAP, or BiLevel prior approval, submit a polysomnogram that meets minimum recording and parameter requirements per Clinical Coverage Policy 1A-20 (minimum two hours recorded sleep without device; include staging, airflow, effort, and oximetry).

• Polysomnogram must not be performed by a medical equipment provider.
• Minimum two hours recorded sleep without device and include required sleep parameters.