MAB2026070105

REQUIREMENTS: By July 1, 2026: Durable medical equipment (DME) suppliers, pharmacies, and prescribing providers must implement prior authorization procedures for all wheelchair cushion and accessory prescriptions exceeding three months of use/rental. Specific Actions for Billing Team: - Update billing system templates to flag wheelchair cushion/accessory claims and require prior authorization submission before claim processing - Create documentation checklists for providers to ensure complete submissions include: relevant diagnoses, imaging reports (if available), PT/OT evaluations, medical records showing physical function/disability, independence/dependence documentation, wheelchair coverage proof with detailed specifications (date of purchase, serial number, manufacturer, model, size, accessories), patient body measurements, and detailed product descriptions - For wheelchair accessories specifically: require documentation proving other accessories were attempted and found inadequate/ineffective/contraindicated - For replacement cushions/accessories: implement requirement for documentation showing existing equipment condition, age, repair vs. replacement cost comparison, and alternatives considered - Update claim submission processes to reference PROMISe™ Provider Handbook sections 7.1.2.18 (837 Professional/CMS-1500) or 7.1.2.16 (837 Institutional/UB-04) - Train billing staff and prescribers on new documentation requirements - Establish internal denial prevention process: claims submitted without required documentation will be denied WHO: Billing team, prior authorization staff, and DME/pharmacy providers WHERE: Billing system configuration, claim forms, and provider communication templates CONSEQUENCES: Claims for wheelchair cushions/accessories exceeding three months without complete prior authorization documentation will be denied by MA program.