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 Funding
Terminology to Know
Many of these
terms are defined slightly differently by each insurance company or payer.
However, many rely on the definitions provided by the Department of Social
& Health Services (DSHS) in Washington State. If you understand DSHS
definitions, you will be able to write a better request for equipment
to any payer. The definitions below are paraphrases of the exact regulations
available on the Washington
State DSHS website; the pertinent code number is provided for your
reference. We do not guarantee that the definitions here accurately reflect
DSHS uses of these terms. You should visit the DSHS website and read the
original defintions.
"Medical Necessity"
or "Medically necessary"
These are terms for describing requested service which is reasonably
calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening
of conditions in the client that endanger life, or cause suffering or
pain, or result in an illness or infirmity, or threaten to cause or aggravate
a handicap, or cause physical deformity or malfunction. There is no other
equally effective, more conservative or substantially less costly course
of treatment available or suitable for the client requesting the service.
For the purpose of this section, "course of treatment" may include mere
observation or, where appropriate, no treatment at all. (For the actual
regulations, please see WAC
388-500-0005.)
"Less
costly alternative"
This expression means any item that is less costly but equally effective
at meeting the needs determined to be "medically necessary"
as discussed above. Any request for a device will be denied if a "less
costly alternative" is available. DSHS's Medical Authorization Unit
will inform the provider and/or the client of a less costly alternative
on the basis of the manufacturers' literature in DSHS files. (For the
actual regulations, please see WAC
388-543-1000)
"Augmentative communication
device (ACD)"
ACD means a medical device that transmits or produces messages or symbols,
either by voice output or in writing, in a manner that compensates for
the impairment or disability of a client with severe expressive or language
communication and comprehension disorders. The communication device may
use mechanical or electrical impulses to produce messages or symbols that
supplement or replace speech. (For the actual regulations, please see
WAC 388-543-1000.)
"Device Features"
We use this expression to describe the components and specifications of
AAC devices. These features are covered in depth elsewhere on this web
site in Understanding
AAC Features. It is the term "Less costly alternative"
that forces us to think about device features as we write letters of justification.
Third party payers, in particular DSHS, are generally inclined to substitute
another device that will meet the individual's needs at a lower cost.
They do not do this to be cruel to individuals, but to ensure that the
most people can be served with the same pot of money.
As you select an
augmentative device, you must identify the features of that device that
are medically necessary for this individual. In your letter of
justification. You must rule out all the less costly devices that do not
have those essential features. For more information on device features,
see Understanding
AAC Features on this website.
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