Durable Medical Equipment, Medical Supplies, Prostheses and Orthoses
Payment Policy: Durable Medical Equipment, Medical Supplies, Prostheses and Orthoses Reference Number: FL.CLMS.05 (Medicaid) Product Types: MMA Effective Date: 03/10/2021 Last Review Date: 03/09/2021 Coverage and Billing Guide Sunshine Health provides coverage for medically-necessary Durable Medical Equipment (DME) and medical supplies pursuant to the Statewide Medicaid Managed Care (SMMC) program. Medical equipment is used to manage and treat a condition, illness, or injury. DME is used over and over again, and includes things like wheelchairs, braces, crutches and other items. Medical supplies are used to treat and manage conditions, illnesses or injury. Medical supplies include things that are used and then thrown away, like bandages, gloves and other items. Additional items, including personal toiletries and household items such as detergent, bleach and paper towels may be covered as medically necessary for Long Term Care/Comprehensive members. General Authorization DME and medical supplies may require authorization for Medicaid members prior to delivery. To verify authorization at the code level, please use Sunshine Health’s on-line prior authorization validation process at sunshinehealth.com/providers/preauth-check/medicaid-pre-auth.html All DME and medical supplies require authorization for Long Term Care/Comprehensive members. Codes Not Listed/Priced on Medicaid Fee Schedule Covered procedure codes not listed on the Medicaid Fee Schedule, not priced on the Medicaid Fee Schedule or not specifically referenced in the provider agreement are reimbursable. HCPCS: E0602, E0784, K0606, L7007, L7009 are reimbursed off the Medicare Fee Schedule. All other unlisted or unpriced codes are priced at 105% of the invoice or based on a negotiated Single Case Agreement (SCA).
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