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Dme 15 (Commonwealth of Massachusetts)

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Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA 02111
www.mass.gov/masshealth
MassHealth
Durable Medical Equipment
Bulletin 15
January 2009
TO: Durable Medical Equipment Providers of Personal Emergency Response Systems
(PERS) Participating in MassHealth
FROM: Tom Dehner, Medicaid Director
RE: Personal Emergency Response Systems (PERS): New Monthly Rental Rate, Prior
Authorization, Documentation, and Installation Requirements
New Rate for PERS The Division of Health Care Finance and Policy (DHCFP) has assigned a
Rental new payment rate for the rental of a personal emergency response
system (PERS): Service Code S5161. The rate can be viewed at the
DHCFP Web site (www.mass.gov/dhcfp). DHCFP has adopted this
amendment to 114.3 CMR 22.00: Durable Medical Equipment, Oxygen
and Respiratory Therapy, as an emergency regulation effective February
1, 2009, to implement budget reductions in accordance with M.G.L. c. 29,
§9C.
__________________________________________________________
Change in Requirements Effective February 1, 2009, MassHealth will require in-home installation of
for PERS Installation PERS only if there is no one else available to install the PERS, such as
the member, the member’s caregiver, or a family member. DME providers
of PERS must assess the member’s need for in-home installation when
the provider receives a referral for PERS, and must maintain
documentation of such assessment in the member’s record. If other
options exist for the member to install the PERS, providers may deliver
the PERS to the member by mail (return receipt required). If a PERS is
delivered by mail, then the provider must not submit a claim to
MassHealth for the PERS installation.
__________________________________________________________
MassHealth
Durable Medical Equipment
Bulletin 15
January 2009
Page 2
Changes in PA Effective for dates of service beginning February 1, 2009, MassHealth is
removing the prior-authorization (PA) requirement for PERS. PERS
services provided for dates of service on and after February 1, 2009, will
no longer require PA. Providers who already have a PA for the PERS
monthly rental must continue to put the PA number on the claim when
billing MassHealth, until the PA is exhausted. Do not submit PA requests
for PERS to the applicable Aging Service Access Point (ASAP) or
Massachusetts Commission for the Blind (MCB). Any PAs submitted for
dates of service on and after February 1, 2009, and after will be returned
to the provider unprocessed.
The removal of the PA requirement does not eliminate the provider’s
responsibility to ensure that the PERS is medically necessary in
accordance with 130 CMR 450.204 and that the coverage requirements
for PERS at 130 CMR 409.445 are satisfied. Providers must continue to
ensure that each member’s record includes documentation to support the
medical necessity of the PERS in accordance with 130 CMR 409.434 and
409.445. Additionally, the provider must maintain, in each member’s
record, a copy of the signed and dated Personal Emergency Response
System (PERS) General Prescription Form (see below), the member’s
care plan, and an acknowledgement of receipt of the PERS, signed by
the member or the member’s representative. This documentation must be
made available to MassHealth upon request.
New MassHealth General Effective February 1, 2009, MassHealth will implement a new Personal
Prescription Form for Emergency Response System (PERS) General Prescription Form (see
PERS attached). Sections I, II, III, and IV must be filled out by the PERS
provider, and Sections V and VI must be completed by the member’s
prescribing physician, nurse practitioner, or a member of the prescribing
physician’s or nurse practitioner’s staff before the installation of the
PERS. DME providers of PERS must have this form completed, dated,
and signed by the member’s physician or nurse practitioner, and
maintained in the member’s record, for all PERS installed on and after
February 1, 2009.
Effective February 1, 2009, MassHealth will no longer require the
prescription form to be renewed annually. However, the General
Prescription Form must be renewed and signed by the member’s
physician or nurse practitioner if a member’s medical condition or living
situation changes such that the member may no longer meet the
requirements for coverage of PERS under 130 CMR 409.445.
MassHealth is in the process of amending its durable medical equipment
regulations to reflect these changes.
(continued on next page)
MassHealth
Durable Medical Equipment
Bulletin 15
January 2009
Page 3
Billing Reminder DME Providers of PERS are reminded that an explanation of medical
benefits (EOMB) is not required when submitting claims for PERS if a
member has other insurance.
Questions If you have any questions about the information in this bulletin, please
contact MassHealth Customer Service at 1-800-841-2900, e-mail your
inquiry to providersupport@mahealth.net
, or fax your inquiry to
617-988-8974.
SECTION i (Sections I, II, III, and IV must be completed by the provider.)
Section I (Sections I, II, III, and IV must be completed by the PERS provider.)
Prescribing provider’s name Telephone number
Address
NPI Fax number
Section II
Supplier’s name Telephone number
Address
NPI Fax number
Section III
HCPCS Code HCPCS Code
Section IV
Length of need: _________________________
All questions must be answered “yes” to qualify for a PERS.
1.
Does the member have a medical condition that causes signifi cant functional limitations or
incapacitation that will prevent the member from using other methods of summoning assistance
in an emergency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
yes no
2.
Does the member have a functioning land-line phone that can accommodate a PERS? . . . . . . . . yes no
3.
Does the member live alone or is routinely alone for extended periods of time such that the
member’s safety would be compromised without the availability of a PERS unit in the home?. . . .
yes no
4.
Is the member able to independently use the PERS to summon help? . . . . . . . . . . . . . . . . . . yes no
5.
Does the member understand when and how to appropriately use the PERS? . . . . . . . . . . . . . yes no
6.
Is the member at risk of moving to a more-restrictive supervised setting, OR is the member at
risk for falls or other medical complications that may result in an emergency situation? . . . . . . .
yes no
Section V (Sections V and VI must be completed by the member’s prescribing physician, nurse
practitioner, or prescribing physician’s or nurse practitioner’s staff.)
Member’s name MassHealth ID number
Address Telephone number
Date of birth Gender Height Weight
ICD-9 code Diagnosis
Personal Emergency Response System (PERS)
General Prescription Form
Medical justifi cation for requested item(s)
Commonwealth of Massachusetts
EOHHS
www.mass.gov/masshealth
I certify that I am the prescribing provider identifi ed in Section II of this form. I certify that the medical necessity
information (per 130 CMR 450.204) on this form is true, accurate, and complete, to the best of my knowledge,
and I understand that I may be subject to civil penalties or criminal prosecution for any falsifi cation, omission, or
concealment of any material fact contained herein.
Prescribing provider’s signature/credentials (Signature and date stamps are not acceptable.) Date
This completed form must be maintained in the member’s record.
Section VI
Prescribing Provider’s Attestation and Signature/Date
PERS-GPF (01/09)
Effective date of prescription: __________________
M
F
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Completed 26 July 2020

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