Form 3706
Instructions

Nursing Facility Customized Power
Wheelchair (CPWC) Authorization

05-2012

PURPOSE

To provide required documentation for prior authorization of a Customized Power Wheelchair (CPWC) for an eligible Medicaid resident in the Nursing Facility (NF) program in accordance with 40 TAC §19.2614, Customized Power Wheelchairs, in Chapter 19, governing Nursing Facility Requirements for Licensure and Medicaid Certification.

To document an assessment specific to a resident's needs for a customized power wheelchair. The assessment must be conducted by a physical or occupational therapist, contain required information from the supplier, be certified as medically necessary by the resident's physician, and acknowledged and signed by the NF administrator.

To document the request for a CPWC including:

  • a complete description of the specific power mobility base;
  • any attached customized or fabricated seating system components;
  • any attached accessories not included in the base price; and
  • retail prices for the individual components, including justification for components that would be considered modifications, customizations, adaptations, or part of the power wheelchair or seating system.

PROCEDURE

  • The applicable sections of the form must be completed, signed and dated by the licensed physical therapist or occupational therapist who provided the required assessment information and who measured and documented the required measurements for the requested CPWC.
  • The applicable sections of the form must be completed by the CPWC supplier.
  • The applicable sections of the form must be completed and certified by the resident's physician related to the medical necessity of the requested CPWC.
  • The completed form must be signed and dated by the NF administrator.
  • The completed form must be submitted by the NF in which the resident is receiving Medicaid nursing facility services.
  • Submissions by entities other than the NF will not be processed.
  • The CPWC must not be purchased before the NF confirmation of approval and authorization of the CPWC request through the Medicaid Eligibility Service Authorization Verification System (MESAV).
  • All required information must be documented on the form and in the format provided in accordance with instructions for the completion of the form and policies related to the process. Note: All requests for authorization of a CPWC are subject to 40 Texas Administrative Code, Section 19.2614, and Form 3706, instructions and Attachment 1, DADS Policy for Authorization of Nursing Facility Customized Power Wheelchair (CPWC).
  • Requested information in all sections must be completed before submission to Texas Medicaid and Healthcare Partnership (TMHP).
  • Incomplete forms will not be accepted.
  • All policy and procedures must be followed in Form 3706, instructions and Attachment 1.

When to Prepare

The required information must be prepared, submitted and approved when an NF will be seeking prior authorization and subsequent reimbursement for the purchase of a CPWC for a Medicaid-eligible resident of the NF.

Note: It is each provider's responsibility to check the client's Medicaid eligibility at the time each service is provided to verify eligibility. Any services provided while the client is not eligible cannot be reimbursed by TMHP.

Form Retention

The original of the form must be kept by the NF for no less than five years and 90 days after purchase, or as long as the resident/individual maintains ownership of the chair, or until all litigation, claims or audit findings are resolved, whichever is longer.

GENERAL INSTRUCTIONS

Complete the form and submit by:

  • Fax to: TMHP LTC Program Authorization Department at 1-512-514-4223, or
  • Mail to: TMHP LTC Program Authorization Department, P.O. Box 200765, Austin, TX 78720-0765

The NF must keep a copy or the original form in its records. For help completing the form, call the TMHP Services Program Contact Center at 1-800-626-4117 and select Option 2.

For questions concerning CPWC billing, call the TMHP Services Program Contact Center at 1-800-626-4117 and select Option 1.

The form must be legible. Print or type the requested information for each part of the form unless a signature is indicated. If any area of the form is illegible, the form will not be processed.

In any part of the form where a signature is requested, an original signature is required. Signature stamps, date stamps and electronic signatures will not be accepted. If any of the required original signatures are missing, the form will be considered incomplete.

Documentation to support medical necessity of the service or equipment must be current, signed and dated by a physician (Medical Doctor or Doctor of Osteopathic Medicine) before services/components are purchased.   

Enter Not Applicable or N/A for sections that do not apply to the specific question or statement.

DETAILED INSTRUCTIONS

Note: If a section, statement or question on the form appears to be self-explanatory, instructions are not provided.

Is this submission a request to transfer the authorization of a CPWC to a new facility? — Check Yes or No. If Yes, complete only Sections A, B, F and G and submit the form.)

Section A. Resident-Related Identifying Information

The resident must be at least age 21 to be considered for a CPWC. If the resident is under age 21 and is a THSteps-eligible NF resident who has a medical need for a CPWC, a request for a CPWC must be submitted through THSteps-Comprehensive Care Program (CCP). Refer to the Texas Medicaid Provider Procedures Manual, at www.tmhp.com/Manuals/TMPPM/Output/Frameset.html for eligibility information.

When a request for a CPWC is approved or denied, letters are sent to the resident or the person identified as the resident's legally authorized representative (LAR), using the corresponding addresses entered in this section.

The nursing facility completes and verifies the information in Section A of the form.

Resident's Name — Enter the name of the resident for which the request is being made, as it appears on the resident's monthly Medicaid statement.

Resident's Medicaid No. — Enter the resident's Medicaid number as it appears on his monthly Medicaid statement.

Date of Birth — Enter the resident's date of birth as it appears on his monthly Medicaid statement.

Is resident age 21 or older? — If the resident is 21 years of age (or older) at the time the form is completed, check Yes. If the resident is under the age of 21, check No.

Name of Nursing Facility — Enter the name of the nursing facility (NF) where the resident lives that is submitting the request for the CPWC.

Nursing Facility Address — Enter the street or mailing address that will be used by TMHP to send any letters of approval/denial for the request.

City, State, ZIP Code — Self-explanatory.

Resident's Legally Authorized Representative (LAR) Name — Enter the name of the LAR, if applicable. Note: An LAR is a person authorized by law to act on behalf of the resident and may include a legal guardian, power of attorney holder, parent of a minor or managing conservator of a minor. If the resident does not have an LAR, do not enter a name in this space.

Resident's LAR's Area Code and Telephone No — Self-explanatory.

Resident's LAR's Address — Enter the street address where the LAR receives mail.

City, State, ZIP Code — Self-explanatory.

Section B. Nursing Facility Identifying Information

The NF completes and verifies the information in Section B of the form.

The NF must designate and document a primary contact for the request.

When a request for a CPWC is denied, approved or when TMHP may need to request additional information regarding a CPWC request, letters are sent to the NF using the identified contact person and address contained in Section B.

Nursing Facility Name — Enter the name of the resident's current NF that is submitting the request for the CPWC.

DADS Contract No — Enter the NF's DADS contract number.

NPI No — Enter the NF's National Provider Identification (NPI) number.

Nursing Facility Address — Enter the mailing address that will be used by DADS to send a letter of approval or denial of the submitted request.

City, State, ZIP Code — Self-explanatory.

Primary Contact Name and Position — Enter the name and position/job title of the NF's staff who will be the point of contact for the requested CPWC.

Area Code and Telephone No. — Enter the area code and telephone number where the NF's primary contact can be reached.

Nursing Facility Area Code and Fax No. — Enter the area code and fax number.

Section C. Therapist Identifying Information and CPWC Assessment

The physical therapist or occupational therapist must complete the information in Section C of the form. Section C includes the "CPWC Assessment" and the "Measuring Worksheet."

Therapist's Name and Title — Enter the name and title of the therapist who is administering the CPWC assessment and check the box for Occupational Therapist or Physical Therapist.

Is the therapist employed by the nursing facility? — Check Yes if the therapist administering the assessment is an employee of the NF. Check No if the therapist is contracted by the NF to administer the assessment.

Therapist's Area Code and Telephone No. — Self-explanatory.

Therapist's Area Code and Fax No. — Self-explanatory.

Therapist's Employer Name — Enter the name of the NF, company or person that employs the therapist.

Mailing Address — Enter the address for the therapist's employer.

City, State, ZIP Code — Self-explanatory.

CPWC Assessment (Completed by Therapist)

This section is filled out by the occupational therapist or physical therapist and all parts must be complete and legible.

I. Neurological Factors

Indicate resident's muscle tone: — Check the box for Hypertonic, Absent, Fluctuating or Other.

Describe — give a brief description for each of the following:

  • resident's muscle tone;
  • active movements affected by muscle tone;
  • passive movements affected by muscle tone; and
  • reflexes present.

II. Postural Control

The therapist checks the appropriate box (Good, Fair, Poor or None) for the resident's:

  • Head Control
  • Trunk Control
  • Upper Extremities
  • Lower Extremities

III. Medical Surgical History and Plans

The therapist answers the questions and provides brief descriptions regarding the resident.

Is there a history of decubitus/skin breakdown? — Check Yes or No. If Yes, the therapist provides an explanation.

Is there a current decubitus/skin breakdown? — Check Yes or No. If Yes, the therapist explains the wound stage and dimensions.

Describe orthopedic conditions and/or range of motion limitations requiring special consideration (i.e., contractures, degree of spinal curvature, etc.). — Self-explanatory.

Describe other physical limitations or concerns (i.e., respiratory). — Self-explanatory.

Describe any recent or expected changes in medical/physical/functional status. — Self-explanatory.

If surgery is anticipated, indicate the procedure and expected date. — Self-explanatory.

IV. Functional Assessment

The therapist answers the questions and provides brief descriptions regarding the resident.

Ambulatory Status — The therapist checks the box for Nonambulatory, With assistance, Short distance only or Community ambulatory.

Indicate the resident's ambulation potential... — The therapist is reminded that residents who ambulate more than 10 feet independently do not qualify for a CPWC and then checks the box for Expected within 1 year, Not expected, or Expected in the future within a period of years.

Can the resident use a modified manual wheelchair for mobility? — Check Yes or No. If Yes, justification must be provided for the requested CPWC.

Is the resident totally dependent upon a wheelchair? — Check Yes or No. The therapist explains why the resident is totally dependent upon a wheelchair.

Indicate the resident's transfer capabilities. — The therapist checks the box for Maximum assistance, Moderate assistance, Minimum assistance or Independent.

Is the resident tube fed? — Check Yes or No. If yes, the therapist must explain.

Feeding: — The therapist checks the box for Maximum assistance, Moderate assistance, Minimum assistance or Independent.

Dressing: — The therapist checks the box for Maximum assistance, Moderate assistance, Minimum assistance or Independent.

Describe other activities performed while in the CPWC... — The therapist also describes access to equipment while in the CPWC to include any equipment that may be mounted or adapted to the CPWC such as an augmented communication device or other.

V. Environmental Assessment

The therapist answers the questions and provides brief descriptions regarding the resident.

Is the resident's living environment accessible to the CPWC? — Check Yes or No.

Are ramps available in the resident's setting? — Check Yes or No. If applicable, identify and describe the resident's current and potential for participation in an educational or vocational setting.

If there is a current or potential educational/vocational setting identified above, complete Items a. – e.

  1. Name of education/vocational site: — Self-explanatory.
  2. Is the accessible to the requested CPWC? — Check Yes or No.
  3. Are ramps available? — Check Yes or No.
  4. Has a therapist from the educational/vocational setting been involved in this assessment? — Check Yes or No.
  5. Name of Therapist; Area Code and Telephone No.: — Self-explanatory.

Complete the remaining items for all CPWC requests. — Self-explanatory.

Describe special accommodations required to charge the energy source for the CPWC (nursing facility and/or educational/vocational setting). — Self-explanatory.

Describe how the CPWC will be transported. — Self-explanatory.

Describe where the CPWC will be stored (nursing facility and/or educational/vocational setting). — Self-explanatory.

Describe other types of equipment that will interface with the CPWC (nursing facility and/or educational/vocational setting). — Self-explanatory.

VI. Requested Equipment

The therapist completes this section.

Describe the resident's current seating system, including the age of the system. — Self-explanatory.

Describe the resident's current power mobility base and the age of the base. — Self-explanatory.

Wheelchair Type; Manufacturer; Serial No.; Date of Purchase — Self-explanatory.

Describe why the current system does not meet the resident's needs. — Self-explanatory.

Describe the seating system that is being requested and how it must be customized to meet the resident's specific medical needs. — Self-explanatory.

Describe the power mobility base that is being requested. — Self-explanatory.

Describe the medical necessity for the requested seating system and power mobility base. — Self-explanatory.

Describe any anticipated modifications/changes to the equipment within the next five years. — Self-explanatory.

VII. Customized Power Wheelchairs

The therapist completes each item.

Describe the medical necessity for the CPWC and any accessories such as power tilt or recline. — Self-explanatory.

Is self-propulsion possible but activity is extremely labored? — Check Yes or No. If Yes, explain.

Is self-propulsion possible but contrary to the treatment regimen? — Check Yes or No. If Yes, explain.

How will the CPWC be operated (i.e., hand, chin, puff, etc.)? Note: The resident must be able to operate the power mobility system without an attendant control. — Self-explanatory.

Is a stop switch requested? — Check Yes or No and explain.

Has the resident been evaluated with the drive controls proposed in this request? — Check Yes or No.

Does the resident have any conditions that will necessitate possible change in access or drive controls within the next five years? — If Yes, explain.

Is the resident physically and mentally capable of operating a CPWC safely with respect to other people in the environment? — Check Yes or No. If No, what additional training is required before the resident can become independently mobile in the CPWC? Explain.

With training, is the caregiver capable of caring for and understanding how the requested CPWC will operate? — Check Yes or No. If No, what additional training or arrangements must be made? Explain.

How will training for the power equipment be accomplished? (Include the resident, caregiver(s), educational/vocational staff and others.) — Self-explanatory.

VIII. Measuring Worksheet (Must be Completed by the Physical or Occupational Therapist)

The physical or occupational therapist completes each item.

Resident Name — Same as Page 1, Section A.

Measurement Date — Self-explanatory.

Height, HT* Range, Weight and WT* Range — Self-explanatory. * HT and WT Range Equal, Minus or Plus 20%

Measurements Completed by — Enter the source for the HT* Range and WT * Range.

Use the numbered list beside the diagram to enter the measurements in inches for the following:

1. Top of head to bottom of buttocks
2. Top of shoulder to bottom of buttocks
3. Arm pit to bottom of buttocks
4. Elbow to bottom of buttocks
5. Back of buttocks to back of knee
6. Foot length
7. Head width
8. Shoulder width
9. Arm pit to arm pit
10. Hip width
11. Distance to bottom of left leg (popliteal to heel)
12. Distance to bottom of right leg (popliteal to heel)

Additional Comments/Observations — Self-explanatory.

IX. Certification by Therapist Completing CPWC Assessment (including Section VIII Measuring Worksheet)

The therapist prints his name, provides his title, license type, license number, and then signs and dates the form.

Section D. Supplier Information

The supplier or durable medical equipment (DME) vendor completes all information in this section and certifies the weight capacity of the requested CPWC.

Supplier's Business Name — Self-explanatory.

Area Code and Telephone No. — Self-explanatory.

Supplier's Representative Completing Form — Enter the name of the contact.

Area Code and Fax No. — Self-explanatory.

Address; City/State/Zip Code — Self-explanatory.

Item No.; Healthcare Common Procedure Coding System (HCPCS) Code; Description of Item; Item Price; Quantity and Total Price — The supplier completes all of the information requested and must also furnish information that verifies the manufacturer's suggested retail price (MSRP) for the items listed. This information must also be included with Form 3706 when sent to TMHP for prior authorization.

Supplier Certification and Acknowledgement — The supplier representative certifies the weight capacity (in pounds) of the requested CPWC and signs and dates the certification and acknowledgement. The representative prints his name and provides the National Provider Identifier (NPI) number if the supplier is a contracted Medicaid or Medicare DME provider. If the supplier does not have an NPI, the section is left blank.

The supplier does not get a copy of the decision letter for approval/denial of the CPWC from TMHP. The NF must give a copy of the full and partial approval/denial notices to the supplier to ensure the supplier is aware of the specific decision made by TMHP.

Section E. Physician Information/Prescription

The resident's physician refers to the Item No. in Section D, Supplier Information.

Diagnosis (DX) and Medical Necessity (MN) Information Item No.; ICD-9 Code; Brief Descriptor; MN Justification for Item — The physician provides the information and the functional/mobility status statement.

Physicianís Attestation of MN for Requested CPWC — The physician must provide the date the resident was last seen and duration of need for the CPWC in months or years.

Signature/Attestation – Physician and Signature Date— The residentís physician signs and dates the request for a CPWC.

The attestation statement must include all identifying information including the physician's:

    • license number;
    • Texas Provider Identification (TPI) number; and
    • NPI.

Note: In accordance with 40 TAC, Chapter 19, related to Nursing Facility Requirements for Licensure and Medicaid Certification, Subchapter M, Physician Services; Rule ß19.1205, Physician Delegation of Tasks.
 
§19.1205 (c)  In a Medicaid nursing facility, any required physician task may also be satisfied when performed by a nurse practitioner, clinical nurse specialist, or physician assistant who is not an employee of the facility but who is working in collaboration with a physician. Services must be provided in the context of applicable state laws, rules, and regulations governing the practice of nurse practitioners, clinical nurse specialists, and physician assistants.

Section F. Transfer Request and Medical Professional Attestation

This section must be completed for submissions in which the:

  • Yes box was checked on the top of Page 1 of the form indicating the submission is a request to transfer the authorization of a CPWC to a new NF; and
  • original request for authorization of the CPWC was approved, but the resident has moved to a new NF before the CPWC could be delivered by the supplier.

I. I am formally requesting that the existing... — Enter the residentís name as it appears on the residentís monthly Medicaid statement and the date of transfer to the new NF in the spaces provides.

Name of Facility's Primary Contact (Printed) — Self-explanatory.

Signature – Facility's Primary Contact — Self-explanatory.

Title of Facility's Primary Contact — Self-explanatory.

Signature Date — Self-explanatory.

II. CPWC Medical Professional Certification

Medical Professionalís Name (Printed) — Self-explanatory.

Type of Medical Professional/Title — Self-explanatory.

Signature – Medical Professional — Self-explanatory.

Signature Date — Self-explanatory.

Section G. Acknowledgement and Signature of Nursing Facility Administrator for Initial Submissions and Transfer Requests

An acknowledgement from the NF administrator that he/she is aware of the DME being ordered for the identified resident.

This section must be completed for submissions in which the:

  • primary contact will be responsible for coordinating, gathering and providing to DADS all information required for the successful completion of this request; and
  • primary contact must sign and date the certification and acknowledgement section in order for this form to be processed.

Note: The primary contact is the facility administrator. Only this individual may act as primary contact and sign this certification and acknowledgement.

Name of Nursing Facility Administrator (Printed) — Self-explanatory.

Signature Ė Nursing Facility Administrator — Self-explanatory.

Date — Self-explanatory.

Once this section is complete, the NF must fax or mail only Page 1 and the page with Section F to TMPH Long Term Care (LTC):

  • Fax to: 512-514-4223, Attn: TMHP LTC Program Authorization Dept.; or
  • Mail to: TMHP LTC Program Authorization Dept., P.O. Box 200765, Austin, TX 78720-0765.

Note: Upon approval of the transfer of authorization to the new facility, only the authorization of the CPWC will be transferred to the new facility. The authorization for any assessments will remain with the facility that originally acquired the authorization for the CPWC.

Form 8706, Attachment 1, DADS Policy for Authorization of Nursing Facility Customized Power Wheelchair (CPWC)