In April, 2020 we contacted Healthfirst and inquired as to whether or not our patient was covered for orthotics (L3000) and if pre authorization was required. The representative stated that L3000 was a covered code and "no authorization is required at this time." Thereafter, we generated a printout from HF (online) which specifically stated authorization is not required. Subsequently the claim was denied for "no authorization". We submitted a review and reconsideration online to Healthfirst, attaching a copy of the printout. The denial was upheld. How can we get this claim paid?
So the orthotics were not paid by Health First due to a provider specialty restriction, regardless of the managed care plan the patient is enrolled in with Health First. According to the current provider manual for all plans, while orthotics are a covered benefit if the patient meets medical necessity guidelines, the products need to be dispensed by a participating ancillary provider. A podiatrist would be able to order the orthotics and refer the patient to the DME supplier, but the ordering DPM would not be able to bill for the orthotics, whether or not authorization was obtained. Below is the excerpt from the current provider manual that provides additional details regarding the coverage for DME purchases:
10.4 Durable Medical Equipment (DME), Orthotics and Prosthetics, and Medical Supplies
DME, orthotics and prosthetics are covered benefits for Healthfirst members who require such services to aid in the treatment of illness or injury or to improve bodily function. The provider must document in the member’s medical record that these items are medically necessary.
DME may be obtained through a participating DME provider with a provider’s written order and the appropriate authorization from Healthfirst.
If a member is receiving home healthcare services, DME is obtained from the home healthcare provider. This may be a hospital-owned or hospital-operated certified home health agency (CHHA) or another contracted home health agency or home infusion therapy provider. Members who are not receiving home healthcare services may be referred to or may have their provider order directly from DME and/or orthotic and prosthetic vendors that participate with Healthfirst. Healthfirst follows CMS guidelines as it relates to rental periods for all contracted providers.
DME and orthotic and prosthetic vendors must call to obtain prior authorization from Medical Management for all items. Diabetic supplies are limited to Bayer, Healthfirst’s exclusive, preferred manufacturer.