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