Prior authorizations for mobility devices spreads to South Dakota

PIERRE, S.D. - South Dakota has joined the prior authorization bandwagon, but there's a wrinkle.

On Jan. 1, South Dakota's Medicaid program began requiring prior authorizations for most mobility devices, as is the case for Medicaid programs in most states and for Medicare in a number of states. But South Dakota will also require prior authorizations for repairs or replacement of parts or accessories.

“Our main concern is for the repairs,” said Cindy Coy, the business office manager for home health, hospice and HME for Avera Home Medical Equipment in Sioux Falls, and the South Dakota chairwoman for the Midwest Association of Medical Equipment Services. “The question we can't get answered is, how long will it take to get prior authorizations?”

The state will require prior authorizations for: repairs or replacement of parts or accessories if the submitted combined charges for parts and labor will be $1,000 or more; for repairs or replacement of parts or accessories that are less than 365 days old; and for miscellaneous parts billed with HCPCS code K0108 when the submitted charge for the part will be $400 or more.

To get wheelchair users “back up and running” in a timely fashion, the state's turnaround time for approving prior authorizations for repairs would have to be within 24 hours, Coy says.

“If something breaks, we need to take care of it right away,” she said. “I don't even think repairs should be included.”

Whether or not states require prior authorizations for repairs varies from state to state, says Don Clayback, and for those that do, he emphasizes the need to create reasonable thresholds. For example: Maybe a state doesn't require prior authorizations for the first two batteries in a 12-month period, but it does for anything over and above that.

“That way the provider can make these repairs in a timely manner and it doesn't tie up the administrative process,” said Clayback, executive director of NCART.

While Coy has concerns about requiring prior authorizations for repairs, she approves of the process, in general.

“We put out some high-end wheelchairs and there are a lot of dollars included in that,” she said. “If we can get a prior authorization, we feel much better about providing that chair and knowing we're going to get paid for it.”