Services: Insurance Verification, Documentation, Authorization
Wheelchair Seating Service has a complete administrative team that specializes in verification of insurance and insurance benefits, coordination with medical professionals to obtain medical documentation, coding of all equipment for insurance submission, acquisition of authorization for rehabilitation equipment, and billing. If there are any questions on insurance or status on orders, clients can contact any Wheelchair Seating Service PSA at 734-971-8286.
Depending on the third-party reimbursement provider, some or all of the following documents may be required:
- Initial Prescription: All evaluations require an initial prescription for evaluation for rehabilitation equipment, wheelchair, and/or seating systems. This initial prescription must be written by either a physician or a nurse practitioner. The initial prescription may be hand-delivered to Wheelchair Seating Service or faxed to 734-971-8922.
- Letter of Medical Necessity: Most medical equipment requires a letter of medical necessity from a medical professional to justify the medical and/or functional need of the recommended equipment. At Wheelchair Seating Service, all evaluations are completed by a RTS along with a therapist and/or a physician. Generally, upon completion of the initial evaluation, the therapist will create a letter of medical necessity (LMN) justifying every component of the equipment that has been recommended during the evaluation. The administrative team at Wheelchair Seating Service facilitates having the LMN signed by the recommending physician. It can then be submitted to insurance, along with other support documents.
- Detailed Prescription: Upon determination of which equipment most adequately addresses a client’s medical needs, the Rehabilitation Technology Supplier will provide the Patient Service Assistant (PSA) with a breakdown of all necessary parts/items that are needed to complete the order. The PSA then creates a detailed physician prescription that is forwarded to the physician for review. The physician has the option of signing if she/he agrees or contacting the team to modify as needed. A physician-signed detailed prescription is required for any order prior to submitting to insurance for a prior approval.
- Physician Face to Face Mobility Evaluation and Subsequent Physician Notes: Medicare requires physician documentation to support all equipment requests. Patients who require powered mobility devices will need to have a face to face visit with a physician in which their mobility needs are discussed. The physician documentation from that visit must specifically state that the client’s mobility needs were discussed and a general statement regarding what the client needs and why. Medicare has established an algorithm (MS Word) for physicians to follow to determine which equipment is required and what needs to be ruled out if the physician is recommending powered mobility.
The documentation from the physician must be received by the RTS within 45 days of when the client saw the physician. If the necessary documentation is not received within that 45 day window, then the client must see the physician again and new physician notes are necessary.
In conjunction with the physician notes, a detailed letter of medical necessity (generally written by the therapist) needs a physician attestation statement such as “I concur with the findings”, as well as the physician’s signature.
- Prior Approval: Upon receiving all signed documentation from the physician and therapist, the WSS staff will submit the necessary documentation to the appropriate insurance to obtain a prior authorization for the recommended equipment. Certain third-party payers allow for a prior authorization to be obtained, assuming medical necessity has been met. The prior authorization provides an approval for payment for the requested equipment once it is delivered. If a prior authorization request is denied, an appeal process is available. The prior authorization process may require a few days to a few months depending on the particular third-party payer.
- ADMC: The Advance Determination of Medicare Coverage is a Medicare process which allows providers of durable medical equipment (DME) the opportunity to determine whether “medical necessity” has been met prior to dispensing the requested equipment. ADMCs can not be utilized for all equipment, but can be processed for items such as ultralight weight manual wheelchairs, tilt in space manual wheelchairs, and certain power wheelchairs. This is not a guarantee of payment. However it does give providers the knowledge that they have met “medical necessity” and that the likelihood of coverage for certain higher end rehab equipment will be provided.
Documentation that is required for submission for an ADMC includes:
- detailed prescription
- face-to-face physician evaluation prescription
- Physician progress notes from the face-to-face evaluation
- The face-to-face evaluation prescription and the progress notes from that face-to-face visit
- letter of medical necessity (LMN) and physician's written attestation statement of concurrence