Documentation of Orders

This documentation is required whether the Durable Medical Equipment, prosthetics, orthotics, and supplies (DMEPOS) requires authorization or not.

Dispensing Orders

Dispensing orders are limited Durable Medical Equipment (DME) orders that are written, faxed, or verbal.

For any DME/supply item to be covered by PrimeWest Health, the supplier must have an order from the prescribing physician before dispensing the item. Acting within the scope of practice, the prescribing provider may be a Clinical Nurse Specialist (CNS), nurse midwife, nurse practitioner (NP), physician, podiatrist, or physician assistant (PA).

PrimeWest Health requires that providers dispense one month of supplies at a time. Providers may not ship items on a regular, monthly basis without an indication from the member, family member, or authorized representative that the supply is needed.

Except for items requiring a written order prior to delivery, the “dispensing” order may be a written order (original or fax) or a verbal order. The order must contain the following:

1. Description of item
2. Name of member
3. Name of physician
4. Date of order

The supplier must maintain documentation of the dispensing order and present it to PrimeWest Health upon request. Documentation may be a photocopy, a facsimile image, electronically maintained, or an original “pen-and-ink” document. Follow the requirements for electronically maintained records as stated in Minnesota Rules 9505.2190, subp. 1, and 9505.2197.

Detailed Written Orders

Detailed written orders contain the dispensing order and follow Medicare guidelines. Detailed written orders must contain the handwritten or electronic signature of the treating physician. Detailed written orders are in addition to the dispensing order, as described above. Detailed written orders may be a photocopy, facsimile image, electronically maintained, or the original “pen-and-ink” document. Follow the requirements for electronically maintained records as stated in Minnesota Rules 9505.2190, subp. 1, and 9505.2197. The treating provider must sign and date the detailed written orders before the claim is submitted to PrimeWest Health. PrimeWest Health will not cover DME or supply items if the supplier has only a verbal order when the claim is submitted.

A detailed written order must include the following:

1. The member’s name and address
2. A detailed description of the item
3. The handwritten or electronic signature of the treating physician (See Minnesota Rules 9505.2197 for details about electronic signatures)
4. The date the order is signed (the physician must enter the signature and date, and it cannot be a stamp or other substitute)
5. If the item has been dispensed prior to the date the detailed written order is signed, the order must specify the start date
6. All options or additional features which will be separately billed or which will require an upgraded code
7. A description narrative (e.g., “lightweight wheelchair base”) or a brand name and model number
8. Rented item orders (must include the length of need)
9. Accessories or supplies provided on a periodic basis (must include the quantity used, frequency of change or use, and length of need)

Someone other than the treating provider may complete the detailed description of the item; however, the treating provider must review, sign, and date the order.

New Order

A new order is required at the following times:

1. An order changes for accessory, supply, drug, etc.
2. Yearly (even if there is no change in the order), for specific items only
3. The item is replaced
4. The supplier changes

Re-Order

1. Requests must come from the member or an authorized representative each time additional supplies are needed.
2. It is acceptable for medical supply providers to call the member to verify a re-order.
3. Automatically shipping supplies without the member’s confirmation is not acceptable.

Medical Records

Medical records must contain the following information:

1. The medical condition to substantiate the necessity of the type and quantity of items ordered and for the frequency of use or replacement (if applicable)
2. The diagnosis and other pertinent information including duration of the condition; clinical course (worsening or improvement); prognosis, nature, and extent of functional limitation; other therapeutic interventions and results; past experience with related item; etc.
3. The clinical information supports the medical necessity for the item and substantiates the information on a supplier prepared statement or physician attestation, if applicable. Clinical information:
   1. is not limited to the physician’s office records;
   2. may include hospital, nursing home, or home health agency records; and
   3. may include records from other professionals including nurses, physical therapists (PTs) or occupational therapists (OTs), prosthetists, and orthotists.

PrimeWest Health may request this information in selected cases. The supplier is liable for dollar amount involved if the information is not received, or does not substantiate medical necessity.

Neither a physician’s order, a supplier-prepared statement, nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician.

Supplier Documentation

The medical supplier must have the following information on file:

1. The original detailed written order
2. Member’s diagnosis from the testing physician
3. Any information required for use of specific modifiers or attestation statements
4. Adequate information to assure that coverage criteria for an item has been met
5. Information in the medical record must adequately support the medical necessity for the item, or the supplier is liable for the dollar amount involved
6. Proof of delivery documentation
7. The dispensing order

Method 1: Supplier delivering items directly to the member or authorized representative:

1. The delivery slip must be signed and dated by the member or authorized representative to verify the DME/supply item was received.
2. The date of the signature on the delivery slip must be the date DME/supply was received by the member or authorized representative.
3. The delivery slip must include the member’s name, quantity, a detailed description of the item(s) delivered, brand name, and serial number (if applicable).
4. The date of service (DOS) on the claim must be the date the DME/supply item was received by the member or authorized representative. An exception to this would be when an item must be billed using a date span and the quantity dispensed crosses over into next month.

Method 2: Supplier utilizing a delivery/shipping service to deliver items:

1. Acceptable proof of delivery includes the delivery service’s tracking slip and the supplier’s shipping invoice.
2. The supplier’s shipping invoice must include the member’s name, quantity, detailed description of the item(s) delivered, brand name, serial number (if applicable), and delivery service’s package identification (ID) number associated with member’s package(s).
3. The delivery service’s tracking slip must reference the member’s package(s), delivery address, and the corresponding package ID number given by the delivery service.
   1. Without the delivery service’s tracking log that identifies each individual package with a unique ID number and delivery address, the item will be denied and any overpayment will be recouped.
   2. When the member denies receipt of an item, the item will be denied and an overpayment will be recouped, unless the supplier maintains a detailed shipping invoice and the delivery service’s tracking log.
4. Mail order DME/supply items: The DOS on the claim must be the shipping date.

Method 3: Delivery of items to an long-term care facility (LTCF) on behalf of the member:

1. Proof of delivery must be maintained in the supplier’s records as described in Methods 1 and 2.
2. Suppliers must work with the LTCF staff to implement inventory control to ensure the following:
   1. The LTCF received delivery and was provided with receipt of what was delivered
   2. Supplies were identified and retained for use only by intended members
   3. Intended members use the supplies
   4. Suppliers receive proof of delivery from the LTCF
3. Medical records in the LTCF must document use of all supplies/items billed to PrimeWest Health. Documentation may be in the nurse’s notes of a special treatment record or form.
4. The DOS on the claim must be the date the DME item was received by the LTCF if delivered by the supplier, or the shipping date if the supplier used the delivery/shipping service.

The only exception to the DOS on the claim is when items are provided in anticipation of discharge from a hospital or LTCF. If the DME item is delivered to a member in a hospital up to two days prior to discharge (home) and for the benefit of the member for the purpose of fitting or training of the member in its use, the supplier must bill the DOS on the claim as the date of discharge (home) and must use POS “12” (home).

All services that do not have appropriate proof of delivery from the supplier will be denied, and all overpayments must be returned to PrimeWest Health.

Hospitalized Members

Except as noted in Supplier Documentation, do not bill for medical equipment and supplies ordered for subsequent use in the member’s home prior to the date of the member’s discharge (home). This includes the following:

1. Drugs, supplies used with the DME, or prosthetic devices
2. Surgical dressing, urological supplies, or ostomy supplies applied in the hospital, including items worn home by the member

Suppliers are responsible for delivering the DME to the member’s home.

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