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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. Obtaining POHO – When the Service Coordinator (“SC”) receives a request from the participant (“ptp”), they are responsible for explaining the process AND assisting them with obtaining Proof of Home Ownership (POHO) documents. Types of valid POHO include:
    • Mortgage Statements
    • Annual Property Tax Statements
    • Warranty Deeds
  1. Obtaining LOC – Based on the scenarios listed, a Letter of Consent (LOC) may be required
    • If the ptp is the sole homeowner then the LOC is NOT needed
    • If the ptp owns the home with others, then LOC is needed
    • If the ptp does not own the home, then LOC is needed

How to complete the LOC appropriately:
1. Send the blank LOC form to the ptp/care team via email or fax
2. Tell ptp that the (a) names and signatures of ALL homeowners MUST be on the letter, (b) Full address must be listed, and (c) ALL appropriate authorization boxes MUST be checked off
3. Have ptp/care team email or fax LOC and POHO to SC
4. SC reviews LOC for accuracy and sends it back if incomplete
5. SC upload POHO and LOC to Envolve

Upload POHO and LOC to Envolve as:

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

Email POHO and LOC to: Home_Adaptations@pahealthwellness.com

Example Letters:

LOC if ptp is homeownder with others

LOC if ptp is NOT the homeowner

The SC is required to follow-up with the participant weekly until documents have been received before moving forward with the request

  1. When the documents are received SC can schedule and complete the Comprehensive Needs Assessment (Visit) and adds the request to the care plan.
  • 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.
    • Amount – 1 unit
    • Provider – TBD
  • Complete Service Request Tool (SRT)
    • SRT should indicate the exact modification being requested.

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 

Note: PA Health and Wellness does not differentiate between DME and SME and therefore refer to all items as DME

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 obtaining a script from their Primary Care Physician (PCP).
    • The PCP should send the script to the chosen provider
    • If the PCP sends the script directly to the SC instead, the SC may send the script with request to the chosen provider
      • It is recommended that the SC inquire id the item being requested is covered by the chosen provider prior to sending documents.
  1. The provider should take over from there!
    • The provider will make the request to insurances, otherwise they will communicate with PHW to determine if authorization is required.
  1. NO DME/SME need to be listed on the PCSP and they DO NOT require a SRT

Regarding Recliners

  • 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
    • Two scripts may be required and written as:
      • Chair Portion of a Lift Chair
      • Mechanical Portion of a Seat Lift
  • 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

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