Incontinence Supply Providers: Diaper/Liner Claims Edit Update
June 5, 2009
Medicaid allows for any combination of up to 250 diapers and/or liners per month. Exceeding this service limit over time will result in claims denial.
In preparation for initiation of a claims edit to better enforce service limits for incontinence supplies, the Department reminded providers of the existing policies relating to ordering and dispensing of these products in the November 2008 Medicaid Update. The article alerted providers that claims denials (Edit 00715) would occur if service limits were exceeded through dispensing of excessive quantities and multiple sizes of incontinence supplies to the same beneficiary. The edit was set to deny for DME claims in May 2009 and providers were notified that liners are included in the new editing. Due to the need for system modifications, Pharmacy claims will be subject to the editing in December 2009.
To assist providers in transitioning to compliance with service limits while ensuring beneficiary access to incontinence supplies, liners will be removed from the editing for claims process dates through August 4, 2009. This provides time for providers to resubmit any claims denied since the edit was set to deny, and to explain the service limits to prescribers and beneficiaries. For processing dates on and after August 5, 2009, liners will be added back to the edit. Although the editing will be temporarily modified, service limits for liners/diapers must be observed to avoid future claims denials for both DME and Pharmacy providers. To allow for early refills, 1750 liners/diapers are allowed in a six month period.
The service limit addresses most medically indicated situations of incontinence. For beneficiaries with medical needs that justify quantities in excess of the service limit, new orders and the incontinence treatment plan must be submitted as a prior approval. Please note that the service limit equates to more than 8 diapers/liners per 24 hours. Prior approval is only required when supplies in excess of the service limit are medically necessary.
New orders may be required to reflect the appropriate number of diapers/liners for beneficiaries incontinence treatment plan. An order must specify the quantity of the specific item (diaper, liner) required per month, not the quantity of packages (boxes, bags, etc).
Questions? Contact Medical Prior Approval at 1-800-342-3005, option #1.
