In 19 states, if you have Original Medicare and need a power wheelchair or scooter, your provider or supplier should first contact Medicare and request prior authorization. Prior authorization means that Medicare must be asked for permission before you can get a certain service or item. This requirement affects you if you live in one of the following states: AZ, CA, FL, GA, IL, IN, KY, LA, MD, MI, MO, NJ, NY, NC, OH, PA, TN, TX, and WA.
Your provider or supplier must send the prior authorization request to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC). The DME MAC will respond within 10 business days (sooner if your health would be harmed by going without equipment), either approving or denying your request.
If the DME MAC approves prior authorization for your equipment, your supplier will provide the equipment, and you will owe your normal Medicare cost-sharing amounts (deductibles and coinsurances). If the DME MAC denies prior authorization for your equipment, your provider or supplier can request such authorization one more time, giving more reasons for why you need the power wheelchair or scooter. If you are denied again, it is unlikely that Medicare will pay for your DME.
If you choose to get the DME after a denial of prior authorization, your provider should have you sign an Advance Beneficiary Notice (ABN). This notice states that you understand that Medicare will not cover the requested DME and that you will be responsible for the full cost. Make sure you select the option to ask the supplier to still submit a bill to Medicare. If Medicare denies payment, you have the right to appeal.