Reminder: Documentation requirements for recurring durable medical equipment, prosthetic, orthotics and medical supply needs

For all durable medical equipment, prosthetic, orthotics and medical supply items that are provided on a recurring basis, suppliers must contact the member, caregiver or designee before dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a member. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.

Suppliers must not dispense a quantity of supplies exceeding a member’s expected use. Suppliers must be aware of changed or unusual use patterns on the part of their clients. Suppliers must verify with ordering physicians that any changed or unusual use is necessary. Regardless of use, a supplier must not dispense more than the approved monthly allowed quantity at a time.

Documentation requirements

A new prescription isn’t required for routine refill during a valid 12 month period. A new prescription is needed when:

• There’s a change of supplier.
• There’s a change in treating physician.
• There’s a change in the items, frequency of use or amount prescribed.
• There’s a change in the length of need or a previously established length of need expires.
• State law requires a prescription renewal.

For items the patient obtains in person at a retail store, the signed delivery slip or copy of itemized sales receipt is sufficient documentation of a request for refill.

For items delivered to the patient, documentation of a request for refill must be either a written document received from the member or a written record of a phone conversation or contact between the supplier and member. The refill request must occur and be documented before shipment. A past documentation statement by the supplier or member isn’t sufficient.

The refill record must include:

• The member’s name or authorized representative if different than the member.
• A description of each item being requested.
• The date of the refill request.
• The quantity of each item the member still has remaining.

This information must be kept on file and be available upon request.