Section 60 Medical Supplies and Durable Medical Equipment (DME) Update on Pricing and Prior Authorization (PA) Requirements, CR 119002

Jul 28, 2023

On March 23, 2023, the Office of MaineCare Services (OMS), sent notification of a reimbursement methodology change for MaineCare Benefits Manual (MBM), Chapter II, Section 60, DME. Included in this change was removal of manually priced codes from the Section 060 - Medical Supplies and Durable Medical Equipment fee schedule and the addition of a PA requirement for codes that have a description which contains the phrase “miscellaneous,” “accessories,” "not otherwise specified" or "not otherwise classified." We are temporarily stopping the requirement for PAs on the codes identified below until September 1, 2023. Effective September 1, 2023, providers will need to begin submitting PAs again. Each PA submission must include documentation that supports Reimbursement for DME/Medical supplies considered to be “miscellaneous DME/Medical Supplies” as described in Chapter II, Section 60. Types of documentation supporting reimbursement can include Manufacturers’ Suggested Retail Price (MSRP) or an invoice that identifies the cost of the item. This update affects the following HCPC codes.  

  

Code	Description
A4421	Ostomy supply; miscellaneous
A4649	Surgical supply; miscellaneous
A6261	Wound filler, gel/paste, per fluid ounce, not otherwise specified
A6262	Wound filler, dry form, per gram, not otherwise specified
A6549	Gradient compression stocking/sleeve, not otherwise specified
L3649	Orthopedic shoe, modification, addition or transfer, not otherwise specified
L8039	Breast prosthesis, not otherwise specified
L8499	Unlisted procedure for miscellaneous prosthetic services

  

Additionally, the following codes that previously required a PA but did not require documentation supporting reimbursement will now require documentation that identifies the cost of the item for reimbursement.  

  

Code	Description
A6512	Compression burn garment, not otherwise classified
B9999	NOC for parenteral supplies
L3999	Upper limb orthosis, not otherwise specified
V5298	Hearing aid, not otherwise classified

  

If you have any questions regarding reimbursement for DME and Medical Supplies, please contact your Provider Relations Specialist Christina Will.