January 5, 2017

New Prior Authorization Requirement for Some Motorized Wheelchairs

New Prior Authorization Requirement for Some Motorized Wheelchairs

Beginning March 20, 2017, there is a requirement for prior authorization for motorized wheelchairs with the HCPCS of K0856 and K0861. This March date marks the first phase of this requirement, which only includes four states: Illinois, Missouri, New York, and West Virginia.

This initial phase, which includes one state in each of the DME MAC jurisdictions, is limited in scope to identify problems with the process, and resolve them, prior to the second phase, which will begin July 17. 2017 and include all other states.

Since December 2015, CMS has provided an annually updated Master List of items that are potentially subject to the prior approval requirement. These motorized wheelchairs are the first items to be selected for the prior approval requirement.

The information required in the request includes:

  • Proof that the item is covered by Medicare.
  • Proof that all coding and payment rules are met.
  • Evidence that the beneficiary’s medical information that justifies the medical necessity.
  • Relevant supplier documentation.

Once the information is reviewed and approved, either by CMS or a MAC, the decision will be communicated to the requester, with additional guidance to the provider. The decisions are expected to be made within 10 business days, however an expedited review process of 2 business days is available upon request.

If you have questions about the prior authorization requirement, please feel free to contact a member of our Marcum Healthcare team.

Information contained herein is accurate at the time of publication. We recommend that you consult with your Marcum advisor before implementing any action.

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