DHS COVID-19 PROVIDER RESOURCES // OMAP
Medical Assistance Bulletin 09-20-06, 10-20-03,14-20-02. 24-20-01,
25-20-01, 31-20-06: Addition of the Multi-Function Ventilator to the
Medical Assistance Program Fee Schedule
Effective: March 1, 2020; Issued: May 1, 2020
Important Reminder: All providers must revalidate the Medical Assistance (MA) enrollment of each service location every five years. Providers should log into PROMISe™ to check the revalidation dates of each service location and submit revalidation applications at least 60 days prior to the revalidation dates. Enrollment (revalidation) applications may be found at https://www.dhs.pa.gov/providers/Providers/Pages/PROMISeEnrollment.aspx.
Purpose
The purpose of this bulletin is to advise providers that procedure code E0467 “MultiFunction Ventilator” is being added to the Medical Assistance (MA) Program Fee Schedule
effective with dates of service on and after March 1, 2020.
Scope
This bulletin applies to physicians, physician assistants, certified nurse midwives and
podiatrists who prescribe home health services, durable medical equipment, appliances and
medical supplies, as well as medical suppliers and pharmacies who render services to MA
beneficiaries in the Fee-for-Service delivery system. Providers who render services in the
managed care delivery system are to address any billing and payment questions with the
applicable MA managed care organization.
Background
On March 6, 2020, Governor Wolf declared a public health emergency in response to
the presence of COVID-19 in Pennsylvania. On March 13, 2020, as a result of COVID-19, a
nationwide emergency under the Stafford Act was declared.
Discussion
In an effort to get resources to meet urgent patient needs related to COVID-19, the
Department of Human Services (Department) is adding procedure code E0467, defined as
“home ventilator, multi-functional respiratory device” to the MA Program Fee Schedule
effective with dates of service on and after March 1, 2020.
Prior authorization is required for multi-function ventilators that fall under procedure code
E0467.
The department only pays a monthly rental fee for multi-function ventilators that fall
under procedure code E0467, and the RR modifier must be used to indicate rental when billing
procedure code E0467. Payment for procedure code E0467 is only made to medical
suppliers.
Effective with dates of service on and after March 1, 2020, Department is adding
procedure code E0467 with the RR modifier to indicate rental to the MA Program Fee
Schedule ad follows:
Procedure Code
| Description
| Unit of Service
| Limit
| Modifier
| Rate
|
E0467
| Home ventilator,
multi-functional
respiratory
device
| 1
| Montly
| RR
| $1,051.90
|
If a provider determines that a backup ventilator is medically necessary for an MA
beneficiary, a PE is required. An MA enrolled prescriber may submit a PE request through the
1150 Administrative Waiver process according to the process described in their MA Program
Provider Handbook. The MA Program will then make a medical necessity determination and
will either approve, approve other than as requested, or deny the PE request based on the
submitted documentation and will notify the prescriber, the provider and the beneficiary of the
decision. Provider handbooks may be viewed by accessing the Department’s website here.
Procedure
Effective with dates of service on and after March 1, 2020, the Department will pay for
multi-function ventilators as noted in the chart above.
Providers must secure prior authorization for multi-function ventilators that fall under
procedure code E0467 and bill in accordance with the chart above.
Information on MA Program coverage related to COVID-19, to include an FAQ
document, can be found on the Department of Human Services website here.
The Pennsylvania Department of Health has a dedicated page for COVID-19 that
provides regular updates. Click here for the most up to date information regarding COVID-19
Comments and Questions