| (a) Purpose. This section details the requirements
for receiving reimbursement for the provision of, or the performance
of a major modification to, a wheeled mobility system. This section
implements Texas Human Resources Code §32.0425.
(b) Definitions. The following words and terms when
used in this section have the following meanings, unless the context
clearly indicates otherwise.
(1) Occupational therapist (OT)--A person licensed
by the Texas Board of Occupational Therapy Examiners to practice occupational
therapy, as defined in Texas Occupations Code §454.002(4) (relating
to Definitions).
(2) Physical therapist (PT)--A person licensed by the
Texas Board of Physical Therapy Examiners to practice physical therapy,
as defined in §354.1121 of this subchapter (relating to Definitions).
(3) Qualified rehabilitation professional (QRP)--A
person who holds one or more of the following certifications:
(A) a certification as an assistive technology professional
or a rehabilitation engineering technologist issued by, and in good
standing with, the Rehabilitation Engineering and Assistive Technology
Society of North America (RESNA);
(B) a certification as a seating and mobility specialist
issued by, and in good standing with, RESNA; or
(C) a certification as a certified rehabilitation technology
supplier issued by, and in good standing with, the National Registry
of Rehabilitation Technology Suppliers (NRRTS).
(4) Wheeled Mobility System--An item of durable medical
equipment (DME) that is a customized powered or manual mobility device
or a feature or component of the device, including:
(A) seated positioning components;
(B) powered or manual seating options;
(C) specialty driving controls;
(D) multiple adjustment frame;
(E) nonstandard performance options; and
(F) other complex or specialized components.
(c) Roles and responsibilities. The following persons,
when referenced in this section, shall have the following roles in
the provision of, or the performance of a major modification to, a
wheeled mobility system, unless the context clearly indicates otherwise.
(1) The OT is responsible for completing the clinical
assessment of a recipient required for obtaining a wheeled mobility
system. The assessment must include detailed documentation of medical
need for specific mobility or seating equipment and all necessary
accessories.
(2) The PT is responsible for completing the clinical
assessment of a recipient required for obtaining a wheeled mobility
system. The assessment must include detailed documentation of medical
need for specific mobility or seating equipment and all necessary
accessories.
(3) The QRP is required to:
(A) be present for and involved in the clinical assessment
of the recipient;
(B) be present at the time of delivery of the wheeled
mobility system to direct the fitting of the wheeled mobility system
to ensure that the system is appropriate for the recipient; and
(C) verify that the wheeled mobility system functions
correctly relative to the recipient.
(4) A person that is licensed as an OT or a PT, and
is also certified as a QRP, may perform either the role of the therapist
or the QRP during the clinical assessment of the recipient, but cannot
serve in both roles at the same time.
(d) Benefit. Wheeled mobility systems are a covered
home health services benefit when the following criteria are met.
(1) All the requirements for DME, as detailed in §354.1039
of this division (relating to Benefits and Limitations of Home Health
Services) are met.
(2) The wheeled mobility system is provided by an enrolled
DME supplier that directly employs or contracts with a QRP.
(3) An enrolled DME supplier obtains prior authorization
for a wheeled mobility system from HHSC.
(e) Prior authorization requirements. The following
documentation must be submitted in a manner approved by HHSC to obtain
prior authorization for a wheeled mobility system.
(1) A signed and dated physician's or allowed practitioner's
prescription, or other such documentation as directed by HHSC, that
details a wheeled mobility system, including all necessary components
the recipient needs.
(2) A clinical assessment that includes detailed documentation
of medical need for specific mobility or seating equipment and all
necessary accessories, signed and dated by an OT or PT authorized
to perform the assessment.
(3) Documentation in a form or manner directed by HHSC
attesting that a QRP was present for and involved in the clinical
assessment of the recipient.
(4) Any other documentation deemed necessary by HHSC
to adequately explain the medical necessity of the requested equipment.
(f) Requirements for reimbursement. Reimbursement for
the provision of, or the performance of a major modification to, a
wheeled mobility system will be considered only when:
(1) the system is delivered to a recipient by a Medicaid-enrolled
DME provider that directly employs or contracts with, a QRP, and the
QRP was present and involved in the clinical assessment of the recipient
for the requested wheeled mobility system; and
(2) at the time the wheeled mobility system is delivered
to the recipient, the QRP is present and responsible for:
(A) directing the fitting to ensure that the system
is appropriate for the recipient; and
(B) verifying that the system functions correctly relative
to the recipient.
(g) Documentation requirements for reimbursement. The
following documentation must be submitted by the enrolled DME supplier
with the claim for consideration of reimbursement for a wheeled mobility
system in a manner approved by HHSC.
(1) A signed and dated HHSC DME Certification and Receipt
Form as required in §354.1185 of this subchapter (relating to
Provider Compliance with Durable Medical Equipment (DME) Certification
Requirements).
(2) Documentation in a form and manner as directed
by HHSC attesting that a QRP was present at the time of delivery and:
(A) directed the fitting of the wheeled mobility system
to ensure that the system was appropriate for the recipient; and
(B) verified that the wheeled mobility system functions
correctly relative to the recipient.
(h) Effective dates for services provided. The provisions
of this section apply to the following services:
(1) wheeled mobility systems delivered on or after
September 1, 2011;
(2) a major modification to a wheeled mobility system
provided on or after September 1, 2011; and
(3) QRP functions, including participating in a clinical
assessment of a recipient and directing the fitting of a wheeled mobility
system, related to the provision of, or a major modification to, a
wheeled mobility system when:
(A) the wheeled mobility system is delivered on or
after September 1, 2011; and
(B) the QRP functions are performed after the effective
date of the associated rates as determined by HHSC.
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