Attention: DME and CAP Providers Incontinence Supplies Transition to Medicaid State Plan

Previously Covered Community Alternatives Program for Children Waiver Incontinence Supplies Now Covered Under Medicaid State Plan

Effective March 2017, certain incontinence supplies (T4535 and T4539) are no longer covered under the Community Alternatives Program for Children (CAP/C) waiver. These supplies are now covered under the Medicaid State Plan. To receive these supplies, a Durable Medical Equipment (DME) provider must submit a Prior Approval (PA) request using the NCTracks system.

The only required documentation that must be submitted with the DME PA is the e-CAP provider participation notice. This participation notice is generated in the e-CAP system for all direct service providers. This notice must indicate the procedure code (T4535 or T4539), the quantity and the authorization period. The CAP/C case manager will provide this notice to the DME provider.

Note: The miscellaneous code of E1399 (W4047) will not be accepted for these requests.

Transition from CAP/C to State Plan Medicaid Coverage

CAP/C beneficiaries previously approved to receive liners (T4535) and reusable diapers (T4539) under CAP/C may continue to receive these supplies under Medicaid. They will receive the same amount, frequency and duration approved in the CAP/C service plan. No action needs to be taken by the case manager or provider on the transition. The Division of Medical Assistance (DMA) is collaborating with CSRA to set up the PA requests.

Changes Needed to an Approved PA Request

If the DME provider or CAP/C case manager determines the current active PA is incorrect (i.e. NPI, units, authorization period), the following steps must be taken:
 

  1. The CAP/C case manager must update the service plan, determine medical necessity and generate an updated provider participation notice with the correct information reflected.
  2. The updated provider participation notice must be given to the DME provider.
  3. The DME provider must create a new PA and upload the new provider participation notice.
  4. The DME provider must request the current active PA to be VOIDED. On web-entered PAs, write “void PA” in the Comments Section; OR the DME provider can write a note at the top of the new provider participation notice asking that the previous PA be voided.

Ongoing Supplies

Ongoing requests for liners (T4535) and reusable diapers (T4539) for CAP/C beneficiaries will be evaluated annually and during a change in a CAP/C beneficiary’s status to determine medically necessary health care.

  1. Once the case manager determines the medical necessity for liners or reusable diapers as an ongoing need, the case manager will update the service plan to include these specific incontinence supplies and ensure a provider participation notice is generated by the e-CAP system. This participation notice must be provided to the DME provider.
  2. The DME provider will submit the prior approval request for these specific incontinence supplies and upload the provider participation notice in NCTracks. It must include the procedure code of the item being requested, the quantity and the authorization period.  The authorization period cannot be more the 365 days.
  3. If the participation notice is not submitted with the PA or it is incomplete (no procedure code, quantity, or authorization period), the reviewer will send a request for the missing information.
  4. If the participation notice or missing information is not received within the specified timeframe, the PA will be denied.
  5. If the participation notice is received with the correct information as listed above, the PA will be approved within 5 days of receipt of all information.

Newly Identified CAP/C Beneficiaries

Case managers of newly identified and assessed beneficiaries determined to need liners or reusable diapers for medically necessary health care will update the service plan to include previously covered CAP/C waiver incontinence supplies and ensure a provider participation notice is generated by the e-CAP system. This must be given to the DME provider. The DME provider will initiate a PA request for these specific incontinence supplies and upload the supporting provider participation notice in NCTracks.