Section 17-134d-84 - Policy and procedures governing the need for service for oxygen therapy on behalf of Title XIX medicaid recipients(a)Need for ServicesThe Department will pay for oxygen therapy for any recipient who meets the criteria established by Medicare pursuant to sections 1861 (s) (6) and 1862 (a) (1) (A) of the Social Security Act, 42 C.F.R. 410.38 and Medicare Carrier's Manual, Chapter II, Coverage and Limitations, Section 2100.5 including Section 60-4 in the Coverage Issues Appendix of the Medicare Coverage Issue Manual, and as they may be amended from time to time. This includes all medical criteria including medical documentation, laboratory and health conditions, with the exception of (a) (1) and (2) of this section.
(1) A measure of arterial oxygen saturation obtained by ear or pulse oximetry, will also be acceptable when ordered and evaluated by the attending physician and performed under his/her supervision or when performed by a Licensed Nurse, Physician, a licensed supplier of Laboratory services, a Registered Respiratory Therapist or a Certified Respiratory Therapy Technician as recognized by the National Board Of Respiratory Care.(2) Those recipients residing in the home and receiving oxygen therapy prior to the effective date of this regulation may continue to do so as long as the oxygen therapy is continuous. For the purpose of this provision continuous means that oxygen therapy remains necessary and is actively being used by the recipient at the beginning of every rental month. If at anytime the service is discontinued and is prescribed again at a later time the requirements set forth under Sections 1861 (s) (6) and 1862 (a) (1) (A) of the Social Security Act, 42 C.F.R. 410.38 and Medicare Carrier's Manual, Chapter II, Coverage and Limitations, Section 2100.5 including Section 60-4 in the Coverage Issues Appendix of the Medicare Coverage Issue Manual and as they may be amended from time to time must be met. All residents of longterm care facilities must meet the requirements as set forth in the Medicare Carrier's Manual, Chapter II, Coverage and Limitations, section 2100.5; and as they may be amended from time to time; effective upon passage of these regulations in order to receive oxygen therapy services from a MEDS provider. Oxygen concentrators owned by nursing facilities may be used at the discretion of the nursing facility.(3) Prescription Requirements The Certification of Medical Necessity form (Medicare Form HCFA-484) shall be used for all orders of oxygen therapy. This fully completed form must be signed by the prescribing physician. The form shall be completed (1) annually for patients who require oxygen on a lifetime basis, and (2) every six (6) months for all other patients requiring oxygen.
(b)Prior AuthorizationPrior authorization is required only for the rental of stationary gaseous or liquid oxygen systems in LTC facilities. However, if LTC facilities choose to purchase the stationary systems and include the cost in the per diem rate calculation, prior authorization is not required.
(c)Prior Authorization ProcedureProvision of service must be initiated within six (6) months of the date of authorization.
(1) Form W-619 "Authorization Request for Professional Services" is used to obtain prior authorization. The form must be completed and signed by the prescribing physician and the supplier and is submitted to the Department.(2) Authorization Period The initial authorization period for oxygen therapy can be up to 6 months. If the medical need continues beyond the initial authorization period, a request for the extension of the authorization using Form W-619 must be submitted to the Department with documentation by the attending physician, prior to expiration of the authorized period, that service continues to be medically necessary.
(3) The provider of service may request verbal approval from the Department during normal working hours, when such authorization may be given for initial service coverage. Authorization will be based on the Need for Service criteria as described in Section 17-134d-84 subsection (a). A completed prior authorization form must then be submitted to the Department within fifteen (15) working days stating the name of the consultant giving verbal approval and date approval was given.(d)Other(1) It will be the Department's decision to rent or purchase oxygen equipment and supplies except in cases where Medicare is the primary insurance carrier.(2) All equipment purchased by the Department shall be new.(3) All equipment purchased by the Department for a recipient will be the property of the recipient upon receipt by the recipient or her/his representative.(4) The provider will furnish technical assistance to the recipient to teach the recipient and/or his or her family in the proper use and care of the equipment.(5) Used equipment, when rented, must be completely refurbished and in proper condition to meet the recipient's specific medical need.(6) Subject to the aforementioned limitations, exclusions, and definitions, oxygen therapy may be provided to eligible recipients in:(B) Long-term care facilities (LTC facilities will provide oxygen concentrator services to the fullest extent, possible after considering the patient's medical need and capability to ambulate. Only after these considerations have been satisfied and the need for alternative system has been documented will the Department pay a MEDS provider for oxygen services provided to LTC facility residents.)(7) All required documentation must be maintained for at least five (5) years in the provider's file subject to review by the authorized Department personnel. This requirement survives any intervening change of ownership. In the event of a dispute concerning a service provided, documentation must be maintained until the end of the dispute or 5 years whichever is greater.(8) For residents of long term care facilities proper documentation for the coverage of a portable oxygen system for a particular ambulatory patient must be maintained by both the facility and the provider. The supplier should secure from the LTC facility such documentation for their records.(9) Failure to maintain all required documentation may result in the disallowance and recovery by the Department of any amounts paid out for which the required documentation is not maintained and provided to the Department upon request.Conn. Agencies Regs. § 17-134d-84