Update: Durable Medical Equipment, Prosthetic, Orthotics and Medical Supplies Prior Authorization Notice

Date: 02/23/18

Heritage Health (Medicaid):

Nebraska Total Care, in cooperation with Heritage Health Administrative Simplification Committee, has modified its prior authorization requirements for Durable Medical Equipment, Prosthetic, Orthotics and Medical Supplies (DMEPOS). 

Generally speaking, if the Medicaid allowable amount on the Nebraska Medicaid Practitioner Fee Schedule for “DMEPOS” (July 1, 2017) is greater than $750, it will require prior authorization.  If less than $750 allowable amount on the fee schedule, then no prior authorization will be required. These changes are effective 9/1/2017. 

For those codes without an established rate or RNE, please review the Pre-Auth Check tool to validate if an authorization will be required. In a previously published bulletin, Nebraska Total Care provided a list of codes that require prior authorization as well as a list of codes that do not require prior authorization.

The Pre-Auth Check tool remains the source of truth for prior authorization requirements.

This guidance does not prevent Nebraska Total Care from post payment review activities as outlined in the Heritage Health Contract.