Prosthetic and Orthotic (P&O) Devices Billing Guide

Washington Apple Health (Medicaid)

Prosthetic and Orthotic (P&O) Devices Billing Guide

July 1, 2020

Disclaimer

Every effort has been made to ensure this guide's accuracy. If an actual or apparent conflict between this document and a Health Care Authority (HCA) rule arises, HCA rules apply. Billing guides are updated on a regular basis. Due to the nature of content change on the internet, we do not fix broken links in past guides. If you find a broken link, please check the most recent version of the guide. If this is the most recent guide, please notify us at askmedicaid@hca..

About this guide1

This publication takes effect July 1, 2020, and supersedes earlier billing guides to this program. HCA is committed to providing equal access to our services. If you need an accommodation or require documents in another format, please call 1800-562-3022. People who have hearing or speech disabilities, please call 711 for relay services. Services, equipment, or both, related to any of the programs listed below, must be billed using their program-specific billing guides: ? Medical Equipment and Supplies Billing Guide ? Medical Nutrition Billing Guide ? Home Infusion Therapy Billing Guide

1 This publication is a billing instruction.

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Washington Apple Health means the public health insurance programs for eligible Washington residents. Washington Apple Health is the name used in Washington State for Medicaid, the children's health insurance program (CHIP), and state-only funded health care programs. Washington Apple Health is administered by the Washington State Health Care Authority.

Refer also to HCA's ProviderOne billing and resource guide for valuable information to help you conduct business with the Health Care Authority.

How can I get HCA Apple Health provider documents?

To access providers alerts, go to HCA's provider alerts webpage. To access provider documents, go to HCA's provider billing guides and fee schedules webpage.

Where can I download HCA forms?

To download an HCA form, see HCA's Forms & Publications webpage. Type only the form number into the Search box (Example: 13-835).

Copyright disclosure

Current Procedural Terminology (CPT) copyright 2019 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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What has changed?

Subject

Change

Reason for Change

Entire guide

Revised format of entire guide

To comply with accessibility standards

Throughout guide

References regarding physician orders or prescriptions now include advanced registered nurse practitioners and physician assistants as prescribers.

To align with CMS rules and WAC 182-5430500

Coverage Table

Removed HCPCS Code L3257

Housekeeping change to remove noncovered code

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Table of Contents

Available Resources ......................................................................................................... 8 Definitions ......................................................................................................................... 10 About the Program ....................................................................................................... 11

What is the purpose of the Prosthetic and Orthotic Devices (P&O) program? ....................................................................................................................... 11 Client Eligibility ............................................................................................................... 12 How do I verify a client's eligibility?.................................................................. 12 Are clients enrolled in an HCA-contracted managed care organization (MCO) eligible? ................................................. Error! Bookmark not defined.

Managed care enrollment........................ Error! Bookmark not defined. Apple Health ? Changes for January 1, 2020 ................................................. 14

Clients who are not enrolled managed care for physical health services ............................................................. Error! Bookmark not defined. Integrated managed care (IMC) ............ Error! Bookmark not defined. Integrated managed care regions .................................................................. 15 Integrated Apple Health Foster Care (AHFC) ............................................ 16 Fee-for-service Apple Health Foster Care ................................................... 16 What if the client has third-party liability (TPL) coverage?................. 16 Coverage............................................................................................................................ 17 What is covered? ........................................................................................................ 17 What are the general conditions of coverage?............................................. 17 What are habilitative services under this program? ................................... 18 Billing for habilitative services ......................................................................... 18 What if a service is covered but considered experimental or has restrictions or limitations? ..................................................................................... 19 Coverage Table ............................................................................................................... 20 Legend ............................................................................................................................ 20 Who owns the purchased P&O devices and related supplies? .............. 22 Provider Requirements..............................................................................................173

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