Texas Medicaid: DME exceptional circumstances provision

UnitedHealthcare Community Plan of Texas complies with the federal requirement to deliver medically necessary durable medical equipment (DME) under the Home Health DME and Supplies Exceptional Circumstances Provision.

• This provision may be needed when equipment or supplies are not covered under the Texas Medicaid Provider Procedures Manual (TMPPM)
• There is no exhaustive list of DME and supplies covered under the exceptional circumstances provision
  • Federal regulations provide general guidance on allowed equipment that typically wouldn’t be needed by someone without a disability, illness or injury, or supplies that are consumable and disposable items to address an individual’s need 

How to request services under the provision

You must request the exceptional circumstances provision when you submit a prior authorization:

• Submit a prior authorization online or by fax (submission instructions provided below)
• Under Comments, cite you’re requesting the exceptional circumstances provision and list the justification for the specific home health service(s)
  • If the exceptional circumstances provision is cited, you must include a reference and explain the member’s need for the requested home health care service(s)

Examples of what may be covered under the exceptional circumstances provision are, but are not limited to:

• Augmentative communication device (ACD) systems
• Bath and bathroom equipment
• Bone growth stimulators
• Diabetic equipment and supplies
• Hospital beds and equipment
• Incontinence supplies
• IV supplies and equipment
• Mobility aids
• Nutritional (enteral) products, supplies and equipment
• PT/INR monitors and related testing supplies
• Wound care equipment and supplies

How to submit a prior authorization request

You can submit a prior authorization request online or by fax:

• Online: Sign in to the UnitedHealthcare Provider Portal at UHCprovider.com and select Prior Authorizations
• Fax: Complete the prior authorization request form and fax to 877-940-1972

Questions?

Chat with us 7 a.m.–7 p.m. CT from the UnitedHealthcare Provider Portal Contact Us page. You can also contact UnitedHealthcare Provider Services at 877-842-3210, TTY/RTT 711, 7 a.m.–5 p.m. CT, Monday–Friday.

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