Durable Medical Equipment Retroactive Prior Approval Review

With recent guidance from the N.C. Division of Medical Assistance (DMA), NCTracks has made improvements in the consistent processing of Durable Medical Equipment (DME) Prior Approval (PA) requests. Initial PA requests with a ‘submit date’ outside of the ‘requested begin date’ and ‘requested end date’ will be considered retroactive requests and denied. In order to be considered a timely PA request, the ‘submit date’ of the PA must be within or prior to the ‘requested begin date’ and ‘requested end date’ on the PA.

There is no retroactive prior approval for DME except as noted below. A denied retroactive request will include directions on how to respond if you wish to appeal the decision.

In addition, any prior approval request with a begin date greater than 365 days in the past will be denied.

Examples of retroactive requests that will be denied:

Example A:   Submit date, September 14, 2014; Service request period, October 14, 2013 through September 1, 2014.

Example B:   Submit date, September 22, 2014; Service request period, January 12, 2014 through        May 10, 2014.

Example C:   Submit date, October 8, 2014:  Service request period, October 1, 2013 through October 2, 2014.

Retro DME Exceptions

The only exceptions are for requests that are submitted specifically for services that exceed the lifetime expectancies or quantity limitations allowed in clinical policy 5A and 5B.  (See Clinical Coverage Policy No: 5A, Attachment A, C. and Clinical  Coverage Policy  No: 5B, Attachment B; Procedure codes for the lifetime expectancies and quantity limitations.)  If the service being requested exceeds the limitations allowed in policy, then a prior approval must be submitted (regardless of whether the service requires PA) and it must be noted on the PA that it is a request to exceed the policy coverage limitations. This prior approval request will serve as the request to override the policy limitation in NCTracks. The request should include the Certificate of Medical Necessity (CMN) as well as supporting documentation for exceeding the coverage limitations. See Clinical Coverage Policy No. 5A, Section 5.5  and Clinical Coverage Policy No. 5B, Section 5.6 regarding the information that must be submitted with the PA request.

Quantity Example:   One manual wheelchair is approved every 3 years. Mr. Smith received approval for a wheelchair on August 1, 2012. On October 1, 2014, a request was submitted to NCTracks for a 2nd wheelchair for Mr. Smith.  The request included a CMN and a report substantiating that the chair had irreparable damage from a house fire.   The request was approved for a 2nd wheelchair.

For more information about retroactive DME prior approvals, please contact NCTracks at 800-688-6696.