American Speech-Language-Hearing Association

Medicare Speech-Generating Devices Information Packet: Medicare Funding of SGDs

Medicare Speech-Generating Devices Information Packet

The ASHA SGD Committee developed a checklist to assist an SLP in the completion of a SGD funding Request. The SLP Checklist stems from the Regional Medical Review Policy (RMRP) (see Appendix A) issued by Medicare. The items on the checklist reflect the required components of the SLP report for funding by Medicare. SLPs should be aware that when any one of the items in the SLP Checklist is not properly submitted, the SGD funding request will be denied. The recommended SGD and accessories are covered if and when the coverage criteria have been met and medical necessity has been documented clearly in the formal report by the SLP.

SLPs are cautioned that the SLP Checklist reflects the SLP funding documentation requirements ONLY. The SLP Checklist does NOT specify or identify the elements required for a comprehensive augmentative and alternative communication (AAC) assessment. The SGD funding process is not a substitute for exemplary AAC clinical practice. All AAC assessments are individualized and differ according to diagnosis, the individual's abilities, communication needs, as well as other individual variables and environmental factors.

Prior to submitting a SGD funding request, patients must have a formal evaluation of their cognitive and communication abilities by an SLP. For a SGD to be covered by Medicare, it must:

  • be eligible for a defined Medicare benefit category,
  • be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,
  • meet all other applicable Medicare statutory and regulatory requirements.

In addition to the SLP report, other information NOT included in the RMRP is required for Medicare coverage. This required information is collected by the vendor/manufacturer and includes physician's prescription, UPIN, and co-payment check. The SLP may wish to assist in the process of gathering this information with the patient and vendor/manufacturer to expedite the completion of the documentation.

Also, the SLP should be aware that for an item to be considered for coverage and payment by Medicare, the vendor/manufacturer must be able to corroborate the information that has been submitted. Documentation such as the patient's medical records, physician's office records, records from other healthcare professionals, or test reports should be available and can be requested to show that the coverage criteria have been met.

This packet was prepared specific to Medicare funding. However, other funders of SGDs (e.g., Aetna, TriCAre, BCBS) may have adopted similar documentation requirements. Therefore, the information may be used as a reference for a variety of funding agencies.

Roles and Responsibilities of the SLP in the SGD Funding Request Process

In addition to satisfying the expectations of professional conduct outlined in the ASHA Code of Ethics and SLP Scope of Practice, the SLP must:

  • Complete an AAC assessment pursuant to the RMRP outline, recommend the most appropriate device, determine software and/or accessories needed, and determine whether the beneficiary can obtain the most appropriate device (determine whether Medicare covers the device, determine whether the manufacturer will accept Medicare assignment, determine whether the beneficiary can pay full purchase price if not covered or no assignment is accepted).
  • Prepare a written report and supporting information, addressing any required accessories in addition to the device.
  • Obtain a prescription from the treating physician that identifies the device and each accessory.
  • Contact the manufacturer/supplier to determine how claims will be processed and determine whether they will process the entire claim or whether software and accessories must be separate claims.
  • Assemble all paperwork plus necessary payment/co-payment from the beneficiary and forward it to the manufacturer/supplier.

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