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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. Service Coordinator (“SC”) receives a request from the participant (“ptp”) and must do the following:
    • Advise ptp that they will need to provide POHO (stated below)
    • Schedules a Trigger Event Visit to complete the Comprehensive Needs Assessment. 
  1. Complete Comprehensive needs assessment.
    • SC must ensure the request is submitted as follows:
      • 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. 
        • Provider and Amount- TBD 

Do NOT state requested item in the PCSP. SC MUST follow prompt above, or else the request will be denied

  1. Complete Service Request Tool (SRT) 
    • SRT should indicate the exact modification being requested. 
Proof of Home Ownership (POHO) assistance
  • POHO documents 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 grant permission. 
  • Upload POHO to Envolve under document upload, document category: “long term services and supports‘, document type: “POHO”. 
  • Send POHO to Home_Adaptations@pahealthwellness.com 

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. 

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): diapers, pads, wet wipes, gloves, etc. 

Process
  1. SC receives a request from the participant and confirms their insurance.
Medicaid Only

If participant has MEDICAID ONLY insurance, complete the following:

  • Assist the participant with obtaining a script from their Primary Care Physician if applicable, depending on the item being requested. 
    • Fill out and send the Prescription Request Form PDF to the PCP.
  • Complete the Comprehensive Needs Assessment and add the item(s) to the PCSP.
    • Note: Each item must have their own request
  • Complete SRT 
  • Upload the script to Envolve. 
Dual Eligible

If the participant is DUAL ELIGIBLE, complete the following:

  • Confirm with the participant which supply company they prefer to use as some may have preference or prior experience with a certain vendor. 
  • Send a referral for the requested item with the SME Vendor Form PDF to the medical supply company.
    • In most cases, the SC may need to assist the vendor or participant with obtaining a script from the PCP. 
  • SC follows up with the supplier biweekly if applicable. 
  • If the item was successfully covered by insurance, the SC adds all requested items to the PCSP during the NEXT visit. PAHW requires to see all services that the participant is receiving. 
    • It is very important that the provider section in the PCSP states: “This item is going through Medicare” 
    • SRT should NOT be created if the item is going through insurance. 
  • If the item was denied by Medicare: 
    • Confirm the vendor is enrolled with PAHW. 
    • Obtain script and denial documentation from the vendor. 
    • Schedule Trigger Event Visit since a new service is being requested.
    • Add the Item to the services section of the PCSP. 
      • The name of the Vendor that documentation has been received from, will be the provider. 
    • Upload the documentation to Envolve. 
    • Complete Service Request Tool. 
Keep in mind the following: 
  • Monthly Supply Items: 
    • When adding Monthly supply items to the PCSP, they must be added by how much the participant will utilize DAILY. This applies to diapers, pads, wet wipes etc. 
      • PCSP should state: participant needs ‘x’ amount of ‘x’ per day on average 
  • Recliners: 
    • Recliners are only partially covered by insurance and must be added to the PCSP with an SRT. 
    • The SC is required to assist the participant with obtaining a script. 
      • Two scripts are required and must be uploaded to Envolve 
        • chair portion of lift chair 
        • mechanical portion of seat lift 
    • The PCSP must state the following: 
      • “chair portion of lift chair” 
      • Do not add “recliner” 
  • Glove Requests: 
    • Please instruct the participant to first reach out to their HHA/PAS provider for gloves as they are the first provider. 
    • If for some reason the PAS provider is unable to supply gloves then the request may be made by following the above process. 
  • 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.
ItemRequest SpecificsAdditional notes
EnsurePut in amount needed DAILY and flavor Anyone can receive ensure, but they will REQUIRE a script for it, unless they meet one or more of the following criteria:
– Have diabetes
– Have kidney disease
– Had a kidney transplant in the last 3 years

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