SECTION 317:30-5-211.2. Medical necessity

(a)   Coverage. Coverage is subject to the requirement that the equipment be necessary and reasonable for the treatment of an illness or injury, or to improve the functioning of a malformed body member. The member's diagnosis must warrant the type of equipment or supply being purchased or rented.

(b)   Prescription requirements. All DME, except for equipment repairs with a cost per item of less than $250.00 total parts and labor and hearing aid batteries, require a prescription signed by a physician, a physician assistant, or an advanced practice nurse. Except as otherwise stated in state or federal law, the prescription must be in writing, or given orally and later reduced to writing by the provider filling the order. Prescriptions are valid for no more than one year from the date written. The prescription must include the following information:

(1)   date of the order;

(2)   name and address of the prescriber;

(3)   name and address of the member;

(4)   name or description and quantity of the prescribed item;

(5)   diagnosis for the item requested;

(6)   directions for use of the prescribed item; and

(7)   prescriber's signature.

(c)   Certificate of medical necessity. For certain items or services, the supplier must receive a signed CMN/OHCA CMN from the treating physician. The supplier must have a signed CMN/OHCA CMN in their records before they submit a claim for payment. The CMN/OHCA CMN may be faxed, copied or the original hardcopy.

(d)   Place of service.

(1)   OHCA covers DMEPOS for use in the member's place of residence except if the member's place of residence is a nursing facility.

(2)   For members residing in a nursing facility, most medical supplies and/or DME are considered part of the facility's per diem rate. Refer to coverage for nursing facility residents at OAC 317:30-5-211.16.

[Source: Added at 24 Ok Reg 2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 1161, eff 5-25-08; Amended at 29 Ok Reg 473, eff 5-11-12]