Tuesday, February 15, 2011

The Medi-Cal TAR process and DME

Written by Kim Cantrell, CFILC's Director of Programs

A treatment authorization request, otherwise known as a TAR, is a form needed to pre-approve funding for treatment, including Medi-Cal approved assistive technology (AT). The TAR is submitted for Medi-Cal approval before the order is placed and provides medical justification for the AT requested. In almost all cases, to be approved by Medi-Cal TARs must include a medical assessment or physician’s prescription including the recipient’s condition and the benefits that he/she will realize through the use of an appropriate device.

Medi-Cal requires TARs for all AT devices costing more than one hundred dollars. Each year consumers are allowed a certain number of requests without TARs for items under $100 (i.e. crutches, canes). Durable medical equipment (DME), such as wheelchairs and walkers, needs to be approved by Medi-Cal and requires a TAR. The form must be completed properly for the order to be processed.

Completing a TAR requires teamwork between a physician and a Medi-Cal approved DME vendor. The physician describes the medical justification for the request on one portion of the TAR, and the vendor reports the price and describes the equipment requested on another portion. It is the vendor’s responsibility to submit the TAR to Medi-Cal.  

Before the TAR is written, the physician must justify the need for AT to both Medi-Cal and the vendor. The TAR process requires vendor-physician cooperation, so vendors may be reluctant to begin the process until they receive documented support from a physician. The medical justification begins with a physician’s prescription or an AT assessment by an occupational therapist or other qualified evaluator. If you or your physician is unsure what AT is needed, then it is a very good idea to be evaluated. Having a prescription and/or an assessment is a very important preliminary step in the TAR process.

Although the physician and vendor write the TAR, the consumer can assist in the process. Medi-Cal is more likely to deem a requested item medically necessary if they receive a physician’s detailed description of need. It is your responsibility to urge your physician to be as specific as possible when writing the prescription and the TAR. For example, rather than the physician simply writing “power wheelchair,” recommend the paperwork include necessary details such as “power wheelchair with reclining motion is medically necessary.”

Additionally, you can request a letter from the physician, on letterhead, describing your condition and the medical benefits you will realize through the AT requested. Talk to your physician regarding a time line for completing the letter. Due to time constraints, you and the physician may decide for you to write a draft of the letter. Of course, your letter is not intended to replace the physician’s final letter, but serves as a letter of self-advocacy explaining the need for AT in your own words. The final physician’s letter then becomes a team effort between you and the doctor.

Also, ask which person in the physician’s office actually writes the TAR. It may be the physician or it could be a nurse or office assistant. It helps to speak to the person responsible to make sure the TAR includes a detailed account of your needs.

Ultimately, you should strive to provide Medi-Cal with all relevant information regarding your claim. When the TAR request is submitted to Medi-Cal, it should include a prescription and/or assessment, a TAR, and, if possible, a physician’s letter explaining the medical necessity of the item.

If this process becomes overwhelming at any stage, contact an AT advocate. The advocate will help you understand your rights and will work on your behalf to make sure that your needs are being met throughout the TAR process. From the prescription to the delivery of the product, an advocate can facilitate communication with the vendor, the physician, and if necessary, Medi-Cal. If your TAR is denied, it is not too late to contact an advocate. Advocates are located throughout California, and they can help you understand the reason for the denial and how to appeal Medi-Cal’s initial decision.

Medi-Cal has 30 days to respond to your request—either to approve it, to deny it, or to defer it—once the TAR has been received or the request is automatically approved. If Medi-Cal defers the request by asking the vendor for additional information, Medi-Cal then has 30 more days to again approve, deny or defer your request. The potential for deferment of your TAR makes it is critical to provide Medi-Cal with as much information as possible, especially for expensive items.

For custom orders or expensive equipment, Medi-Cal may still contact the vendor with additional questions, even if you submitted a well-justified TAR and supplementary materials. The truth is that the volume of TARs Medi-Cal processes is staggering. According to a Medi-Cal employee, the deferment process allows Medi-Cal to catch up when TAR volume or complicated requests require more time than the initial 30-day period. Unfortunately, the practice of deferring requests is particularly harsh to the waiting consumer. If your TAR request is deferred, an AT advocate can work with you to contact Medi-Cal and ensure a decision is made as soon as possible.

It is important to note that the vast majority of requests are approved or denied within the 30-day period. Hopefully, by using some of the helpful hints described above, you will be able to benefit from the TAR process and receive Medi-Cal approval for the AT you require. 

Have you had to wait for a TAR to be approved? Do you have any other Medi-Cal TAR tips to add?  If so, please leave a comment below. 

3 comments:

  1. Thanks for sharing such useful information..Keep posting such nice articles...

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  2. Thanks for your valuable information.I found it very useful.Keep posting amazing content like this.

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