Pinnacol has developed new guidance on billing, authorizations and referral scripts to assist durable medical equipment, prosthetic, orthotic, and supply (DMEPOS) vendors.
Many treatments and devices do not require prior authorization for payment because they are within the Medical Treatment Guidelines, DOWC Rule 17 and exhibits. However, other devices that are not addressed in the guidelines require prior authorization with a detailed script before the item can be furnished or a bill can be submitted.
For example, a provider should request prior authorization for e-stimulation devices priced over $100 and before a potential purchase. Providers should rent the devices for the first month to determine their effectiveness. The documentation of their effectiveness should include the assessment of functional improvement and decreased pain. For more information on e-stim devices, see this page on our website here.
DMEPOS vendors that supply and bill for DME should use a nationally recognized HCPCS or CPT code when one exists, even if there is no associated fee schedule. Miscellaneous codes are only intended for use when a more appropriate code is not available.
In the event that a code with no value or a miscellaneous code is billed, Pinnacol will request a description of the item, the name of its manufacturer, its product number and a copy of the manufacturer’s invoice. Reimbursement to the DMEPOS will be 120% of the cost of the item as indicated by the manufacturer’s invoice, and no additional PPO discount will be applied. Shipping and handling charges are not separately payable to the DMEPOS vendor.
If you have questions, please contact firstname.lastname@example.org.