Vision appliances, hearing appliances, durable medical equipment, oxygen, medical supplies, prosthetics and orthotics
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This document defines Medicaid (MAD) coverage, prior authorization, service limitations, and reimbursement rules for durable medical equipment (DME), oxygen systems, vision and hearing appliances, augmentative communication devices, prosthetics and orthotics for MAP eligible recipients.
No material clinical or coverage changes in this revision.
Covered Services, Limits and Conditions
Covered services and limitations
Coverage, limitations and conditions for equipment and devices
Claim Form and Payment Rules
| CMS-1500 | Claim form required for vision, hearing, prosthetic/orthotic providers (CMS1500 or successor). |
Prior Authorization, Documentation, and Provider Responsibilities
Obtain prior authorization and include required documentation
Prior authorization is required for hearing appliances, DME, oxygen, medical supplies, prosthetics and orthotics. Prior authorization does not guarantee eligibility for MAD services; services remain subject to utilization review at any point in the payment process. For hearing aids, the MAP eligible recipient's PCP must provide medical clearance on provider letterhead or prescription pad and submit that documentation with the prior authorization request. All prosthetic devices require prior authorization (except a prosthetic limb attached immediately following surgery for traumatic injury while inpatient).
- Prior authorization required for: hearing appliances; DME, oxygen and medical supplies; prosthetics and orthotics (see exceptions for immediate post‑surgical inpatient prosthetic limb).
- Prior authorization does not guarantee eligibility; services remain subject to utilization review at any point in the payment process.
- Hearing aid prior authorization must include PCP medical approval on PCP letterhead or prescription pad and be submitted with the request.
Verify eligibility and use reconsideration process for denials
Providers must verify recipient eligibility and whether the MAP eligible recipient has other health insurance at the time the service is furnished. If a provider disagrees with a prior authorization denial or other review decision, they may request reconsideration per 8.350.2 NMAC.
- Verify recipient eligibility and other insurance coverage at time of service.
- Request reconsideration for denials following the process in 8.350.2 NMAC.
Complete required 60‑day trial rental and document outcomes
A trial rental period of up to 60 calendar days is required for all electronic augmentative and alternative communication devices prior to purchase. At the end of the trial rental, documentation must show the recipient's ability to use the device is improving and that they are motivated to continue use. Prior authorization is required for equipment repairs.
- Complete a trial rental up to 60 calendar days and retain documentation of improving ability and motivation if purchase is recommended.
- Obtain prior authorization for repairs to augmentative communication equipment.
- MAD does not pay for consumable supplies for these devices (e.g., paper, printer ribbons, computer discs).
Key Definitions
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