(A) Coverage.
(1)
Payment for
quantities of incontinence garments or incontinence supplies that exceed the
indicated limit is subject to prior authorization (PA). The default
certificate of medical necessity (CMN)
form is
the ODM 02912, "Certificate of Medical Necessity: Incontinence Items" (rev.
7/2018
7/2024). The CMN
must
include
includes the following elements:
(a) An indication that the individual is at
least thirty-six months of age;
(b)
The applicable diagnosis of the specific disease, injury, developmental delay,
or developmental disability causing the incontinence;
(c) The type of incontinence; and
(d) The type and quantity of incontinence
garments or incontinence supplies being prescribed.
(2)
An increase in
the prescribed quantity of an incontinence item is subject to PA, as is a
change in the type of incontinence item. (No additional authorization is needed
for a decrease in quantity.)
(3)
Similar types of
incontinence garments (e.g., briefs/diapers and underwear/pullons) may be
dispensed together without PA if the aggregate quantity does not exceed the
prescribed quantity or indicated limit for any of the individual items.
(2) Payment cannot be made for items
related to stress incontinence to which no specific physiological,
psychological, or physiopsychological cause can be attributed.
(3) A certification period cannot
exceed twelve months.
(4) A new certification is required
for an increase in the quantity of an incontinence item already prescribed or
for a change in the type of incontinence item. (No new certification is needed
for a decrease in quantity.)
(B)
Requirements,
constraints,
Constraints and
limitations.
(1)
Payment cannot be made for items related to stress
incontinence to which no specific physiological, psychological, or
physiopsychological cause can be attributed.
(2)
PA cannot be
granted for longer than twelve months at a time.
(1)(3)
Incontinence items are dispensed in quantities representing one month's supply.
A provider is expected to verify and document an
individual's current need before dispensing additional items. Medicaid payment
for excessive quantities of items is subject to recovery.A provider must not dispense additional incontinence items
to an individual who already has at least a month's supply on hand. Before
dispensing additional items, therefore, providers must make contact, either
orally or in writing, with each individual (or the individual's authorized
representative) to verify the current need. Providers must keep on file a
summary of this contact, including in particular the following
information:
(a) The quantity of items
requested;
(b) The quantity of items currently
on hand;
(c) The verification date, which
must not be more than fourteen days before the dispensing date;
(d) The full name of the provider's
representative who recorded the quantities reported; and
(e) The full name of the person (the
individual or the individual's authorized representative) who reported the
quantities.
(2)(4) Payment will not be
made for an incontinence item in excess of the
quantity
more incontinence items than
are prescribed or authorized.
Notes
Ohio Admin. Code
5160-10-21
Effective:
7/1/2024
Five Year Review (FYR) Dates:
1/30/2024 and
07/01/2029
Promulgated
Under: 119.03
Statutory
Authority: 5164.02
Rule
Amplifies: 5164.02
Prior
Effective Dates: 05/01/1990, 09/01/1998, 10/01/2004, 04/25/2011,
07/16/2018
