Categories
< All Topics
Print

Home Mod/DME/SME Process

Home Modifications 

Home modifications are defined as environmental interventions aiming to support activity performance in the home. More specifically, home modifications often are changes made to the home environment to help people with functional disability or impairment to be more independent and safe in their own homes and reduce any risk of injury to themselves or their caregivers. 

Examples of Home Modifications include: Grab bars, stair glide, walk-in shower, ramp, VPL, door widening, handrails, railings. 

Process 
  1. Service Coordinator (“SC”) receives a request from the participant (“ptp”) and schedules a Change Event visit to complete a Comprehensive Needs Assessment
    • SC is also responsible for assisting the ptp with obtaining Proof of Home Ownership (POHO). Types of valid POHO include:
      • Mortgage Statements, Annual Property Tax Statements, and/or Warranty Deeds
        • If multiple names are on the POHO document or the participant has a landlord, then a notarized letter is needed.
          • This letter must include: Relationship to the participant, address of the home, and it must state they are granting permission
          • This letter must explicitly give PHW permission to complete a home modification and should NOT specify the exact modification being requested.

The notarized letter MUST be handwritten with a signature. It CANNOT be emailed
The SC is required to follow-up with the participant weekly until documents have been received

  1. Complete the Comprehensive Needs Assessment and ensure the need and request for the Home Mod is put in appropriately.
  • InterRAI sections G and Q must be completed accurately to reflect need for Home Mod. 
    • i.e. participant requests a stair glide but section G shows participant needs limited assistance climbing stairs, and section Q does not indicate that the participant does not need assistance maneuvering through rooms, then the request will be denied. 
  • Signed PCSP with the Home Modification request in the Service Plan.
    • PCSP must state: “Home adaptations evaluation is needed”; and indicate the participants’ barrier. (ie. Home adaptations evaluation is needed, the participant cannot maneuver up and down the stairs to the second floor. The bathroom and bedroom are on the second floor of the home.) 
      • This will allow the evaluator to determine if it is safer to have railings, stair glide, or other modifications in that specific home/situation. 
    • Amount – 1 unit
    • Provider – TBD
  1. Complete Service Request Tool (SRT) 
    • SRT should indicate the exact modification being requested. 
  1. Upload POHO to Envolve under document upload

Document Category: Long Term Services and Supports
Document Type: POHO
File Name: POHO_Ptp last name_Ptp first initial_Ptp ID#_mmddyyyy

If an HA request is denied due to a lack of information and then the information is received after the denial  letter was sent the SC should consider this to be a NEW REQUEST and submit a NEW SRT indicating the NEW DATE the request is being submitted.

NOTE: PAHW will carry out the rest of the process in regards to evaluations and installation quotes. 

NOTE: Building new rooms is EXCLUDED as well as improvements to the home of general maintenance. 

Home Modification Repairs

If the SC has been informed from the participant that they need a repair of any kind to a previously installed modification:

  • The SC should confirm with the participant who the provider was. 
  • The SC may reach out to the provider to confirm if the installation is still under warranty.
    • If the installation is under warranty, the provider should be notified of the repair that is needed so they can schedule to go to the participants home and evaluate.
  • If the installation is no longer under warranty, the SC is required to confirm the make and model number of the modification. 
  • The SC can add this service to the PCSP, including the make and model number.
  • SRT is required

Durable Medical Equipment/ Specialized Medical Equipment 

Examples of DME: (Reusable): wheelchair, walker, recliner, hoyer lift, scooter, hospital bed, cane, commode, etc. 

Examples of SME: (Disposable): wet wipes, barrier cream, gloves, incontinence supplies such as: diapers, pads and liners.

Process

If the Participant is requesting SME or DME:

  1. SC receives the request and assists the participant with asking the Primary Care Physician (PCP)to send a script to their chosen provider
    • If the PCP sends the script directly to the SC instead, the SC may utilize the Vendor form to send the request with the script to the chosen provider.

It is recommended that the SC inquire with the provider if the item is covered BEFORE sending the documents. If it is not, chose a different provider.

  1. If the item was successfully covered by insurance, the SC adds all requested items to the PCSP during the NEXT visit. PHW requires to see all services that the participant is receiving.
    • The PCSP should state: “This item is covered under Medicare (or other insurance)”

Simple DMEs and SMEs do NOT go onto the PCSP until AFTER they are approved/covered by insurance or Authorization is made (unless it is an Exceptional DME, see below)

  • SRT is NOT REQUIRED for any SME or DME unless specified below.
  • If the item is denied by insurance and an authorization is needed, the provider will submit a prior auth to PHW and it will be reviewed
  • If the item is denied by insurance and an authorization is not needed, the provider should be able to supply the item.

If the Participant is requesting custom items:

Any item that is custom to the participant (i.e. it cannot be used straight out of the box) and the cost is equal to or greater than $5,000 is considered Exceptional DME (EDME) and is required to be added to the PCSP and an SRT must be completed

The following items would be Exceptional DMEs and therefore should be listed on the PCSP and have an SRT completed:

  • Manual wheelchairs – no script is needed if ptp is requesting for purchase, PHW does not do rentals
  • Power wheelchairs – no script is needed
  • Power scooters – no script is needed
  • Lift chairs/Recliners*script is needed
  • Shower chairs with tilt/rolling shower chairs with commode*script is needed
  • Tub transfer system (not the typical transfer bench)*script is needed
  • Speech Generating devices*script is needed
  • Repairs to any of the above items – no script is needed

If the item being requested is specific, list it in the PCSP service details as such.

If there is a chosen provider from the participant, they should also be listed on the PCSP. If not, state TBD for Provider

For items that require a script, try to obtain that from the PCP DURING the visit and submit it with everything else. Otherwise get it ASAP.

There may be exceptions to this process depending on the item being requested. PHW will send task on how to proceed in these circumstances.

Regarding Recliners

Lift chairs DO require a script because they are a regular DME, not EDME. PHW will assist with the lift chair process by sending that script to a provider, but they do this to assist the SC.

  • Dual Eligible participant are required by Medicare to have a face to face visit with their ordering physician and the physician should be initiating that request, by writing a script for the item
  • If a script, InterRAI, PCSP, and SRT is provided to PHW for a dual eligible participant with the request, they will send the request to a provider for Medicare processing.
  • If a script, InterRAI, PCSP, and SRT is provided to PHW for a non-dual eligible participant, they will send the script to a provider for a quote.

The Service Coordinator has the ability and it is preferred that they send the script, demographics, primary insurance info to a provider directly. A current PCSP, SRT, and InterRAI must be on file.

If Medicare denies the request, PHW will need a new SRT on file within 48 hours of receiving a quote when Medicare denies.

Keep in mind the following: 
  • Diagnoses: 
    • Items will require a specific diagnosis 
    • Participants may not always be eligible for what they are requesting. 
      • i.e. If your participant is requesting diapers, but your InterRAI reflects that they are not incontinent and they do not have any incontinent diagnosis, then they will not be qualified to receive diapers. 
    • This goes for insurance AND waiver coverage. 
  • Order of Mobility with DME items
    • A participant who is requesting a walker and a wheelchair will need to decide which is more pertinent to their needs.
      • i.e. If the participant already has a wheelchair, they cannot receive a walker, if they have a walker already, they cannot receive a cane. If they start with a cane then they ARE allowed to receive a walker, and then a wheelchair but this cannot go in reverse order.

If you have any additional questions that have not been answered in this policy procedure, please REFRAIN from calling PHW. Instead direct your question(s) to the AVP who will verify this with the AM

Previous HEDIS Assessment Guide
Next OPS-8 Process Guide
Table of Contents