Repairs to Durable Medical Equipment

(A) Prescription Requirements. The MassHealth agency does not require a prescription or a letter of medical necessity for the repair of DME that the MassHealth agency previously determined to be medically necessary for the member. A prescription or LOMN are required if the MassHealth agency has not previously determined the medical necessity of the item requiring repair in order to establish medical necessity for the device. (B) Repairs of Purchased Durable Medical Equipment Requiring Removal from the Member. When member-owned equipment has been determined to be unusable and requires repair, MassHealth will pay for temporary replacement equipment. The provider must attempt to supply, on a rental basis, properly working substitute equipment that is comparable in most respects to the equipment to be repaired. Rental of substitute equipment is covered by MassHealth in accordance with rates established by 101 CMR 322.00: Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment. (C) Repairs of Rented Durable Medical Equipment Requiring Removal from the Member. When a repair service for rented durable medical equipment requires removing the equipment from the member, the provider must supply the member with properly working substitute equipment that is comparable in most respects to the equipment to be repaired. Providers may continue to bill a rental fee in accordance with rates established by EOHHS at 101 CMR 322.00: Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment, but no extra rental charge is allowed for this substitute equipment. (D) Prior Authorization When Total Repair Exceeds $1,000. DME providers must submit a prior authorization request for total repairs or modifications that exceed $1,000 per repair. For purposes of calculating total repair/modification, providers must include parts and components, including labor, based on EOHHS’s rates established at 101 CMR 322.00: Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment. For purposes of calculating the total repair/modification, the amount is inclusive of all HCPCS codes that have “No,” “Sometimes,” and “Yes,” in the Prior Authorization Approval column on the DME/OXY Payment and Coverage Guideline Tool. For purposes of 130 CMR 409.420(D), the total repair cost exceeding $1,000 does not include any applicable corrective mobility system repair add-on payment. (See 101 CMR 322.05(1): Providers Eligible for Add-On Payment). (1) MassHealth pays for repairs to medically necessary mobility systems, including back-up systems, when either the member’s primary or back-up systems are customized, adapted, or modified to the extent that no rental equipment or loaner would be comparable, and the repair is not covered under the warranty (see 130 CMR 409.413(C), (D), and (E)). (2) The DME provider must submit the following documentation with the repair prior authorization request: (a) a completed MassHealth Prior Authorization Request (PA-1) form (if request is submitted on paper); (b) evidence of MassHealth PA for the item requiring repair or a prescription or letter of medical necessity that meets the requirements of 130 CMR 409.416 if the MassHealth agency has not yet determined the medical necessity of the Durable Medical Equipment requiring repair; (c) a description of the customization or modification of the member’s mobility systems, if applicable; (d) an invoice or quote for the repaired or replaced item as applicable; (e) a work order log with the estimated number of hours the repair will take; (f) a detailed description of the circumstances that made the repair necessary; and (g) an explanation as to why the repaired or replaced item is not covered under any warranty. (E) Provider Responsibility. The DME provider who submits a claim to the MassHealth agency for repair of Durable Medical Equipment is responsible for (1) ensuring quality of workmanship and parts; (2) ensuring that the repaired equipment is free of defects and in proper working condition; (3) ensuring that repairs are completed within a reasonable time after requests for repair, and any authorizations required for repair, are received by the provider. Providers must make alternative arrangements such as using subcontractors if the provider is unable to repair within a reasonable amount of time. The MassHealth agency reserves the right to issue additional subregulatory guidance on reasonableness of repair times for specific DME; (4) taking advantage of all manufacturer warranties; (5) complying with the requirements of the Wheelchair Lemon Law (M.G.L. c. 93, § 107) and any other applicable provisions of federal and state laws pertaining to the service provided; (6) providing the member with regular updates regarding the status of the repairs and the expected delivery date of the equipment being repaired; and (7) responding in a timely fashion to a member’s complaint regarding the repair of the equipment. (8) A claim for a mobility system repair performance-based add-on payment pursuant to 101 CMR 322.05(1): Providers Eligible for Add-on Payment must meet any conditions of payment set forth in 101 CMR 322.00: Rates for Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment or described by EOHHS via administrative bulletin or other written issuance to providers, including any reporting requirements under 101 CMR 322.04: Filing and Reporting Requirements. (F) Coverage for Replacement Equipment. Coverage for replacement equipment will be provided only when the existing device or system no longer effectively addresses the member’s medical needs, or if the cumulative cost of the repair exceeds the cost to replace the equipment. (G) Repairs of a member’s Serviceable Backup Power Wheelchair. MassHealth pays for repairs for a member’s serviceable retired backup power wheelchair in the following instances: (1) the DME provider must obtain prior authorization from the MassHealth agency or its designee as a prerequisite for any repair of a member’s serviceable retired backup power wheelchair; (2) the member’s medical complexity prevents them from being able to use a manual wheelchair or loaner power wheelchair when the primary mobility system needs repair; (3) the total cost of the repair of the serviceable backup power wheelchair does not exceed $1,000.00 per calendar year unless the MassHealth agency exercises discretion to approve the total cost of the repair. The MassHealth agency will review requests exceeding $1,000.00 on a case-by-case basis; (4) the MassHealth agency will only pay for the repair of one serviceable backup power wheelchair per calendar year; (5) DME providers must document the serial number of the repaired serviceable backup power wheelchair and submit the documentation listed at 130 CMR 409.420(D)(2)(c), (d), and (e); and (6) all documentation regarding the repaired serviceable backup power wheelchair must remain in the member’s file. (H) Maintenance. MassHealth pays for maintenance repairs, including to a member’s primary mobility system, backup mobility system (see 130 CMR 409.413 (C)) and to a serviceable retired backup power wheelchair (see 130 CMR 409.420 (G)), which require the specialized knowledge of a trained technician. Maintenance repairs identified in the manufacturer’s instructions or manual may be scheduled by the member or DME provider. Mobility system maintenance repairs are not eligible for an add-on payment. (See 101 CMR 322.05(1): Providers Eligible for Add-on Payment.) (I) Corrective Mobility System Repairs. Corrective repairs for mobility systems are eligible for the add-on payment. (See 101 CMR 322.05(1)(b).) (130 CMR 409.421 through 409.425 reserved)