MedicaidCoverageHigh impact
Medicaid Durable Medical Equipment (DME) and Supplies Listing
Aetna Better Health of Virginia·VA · Pediatrics, Gastroenterology, Palliative Care +1 more·Provider Notification
Effective date
Aug 2, 2024
We identified it
Aug 13, 2026
Summary
Aetna Better Health of Virginia has released an updated Medicaid DME and Supplies Listing effective immediately that specifies coverage, reimbursement rates, service authorization requirements, and billing units for enteral/parenteral nutrition pumps, feeding tubes, and nutritional supplements. Billing teams must verify all DME claims use the correct HCPCS codes from this listing, apply appropriate prior authorization requirements (marked as Y or N), and adhere to new fee limits and utilization frequency caps. Items requiring Individual Consideration (IC) pricing now require provider cost documentation (invoice/purchase order) to be submitted with claims for payment at cost plus 30% markup, not to exceed retail.
Action Required
Immediately effective August 2, 2024: (1) Billing team must update billing system to enforce the specific HCPCS codes, fee limits, and service authorization (SA) requirements from this listing for all Aetna Better Health Virginia Medicaid DME claims. (2) For codes marked 'Y' requiring SA (B9000, B9002, B9004, B9006, E0791, E1399/B9998, B4099/B9998, Y0005/B9998, B4105), implement mandatory prior authorization submission to DMAS service authorization contractor before claim submission—claims without SA will be denied. (3) For codes marked 'N' (B4034-B4088), process without prior auth but enforce the specified fee limits and quantity limits (e.g., B4081-B4082 limited to 4/month, B4087-B4088 limited to 1/2 months). (4) For all IC (Individual Consideration) codes (B4100, B4102, B4103, B4104, B4105), require providers to attach itemized invoice or purchase order documentation showing provider cost and MSRP/retail price to every claim—claims will be paid at provider cost plus 30% markup, not to exceed retail. Reject and return to provider any IC claims missing cost documentation. (5) Update claim submission forms and provider communication templates to clarify that rental items (RR designation) are reimbursed as daily rates and no reimbursement is provided for days the recipient did not use the item. (6) Educate billing staff that rental reimbursement limits (e.g., 3 months, 6 months for E0791) cap the rental period, not quantity per day. (7) Confirm that Medicare crossover claims follow established Medicare guidelines and HCPCS codes, not this Medicaid listing. Failure to apply correct codes, obtain required SA, enforce fee/quantity limits, and submit IC documentation will result in claim denials and payment delays.