How to Get Prior Authorization for Incontinence Supplies Covered by Medicaid?

Why do I Need Prior Authorization to Receive Incontinence Supplies?

Prior authorization is required for Medicaid to determine that incontinence supplies are medically necessary to treat a patient’s medical condition. Additionally, it ensures that Medicaid recipients receive high-quality care and are provided with the appropriate medical supplies.

How to Get Prior Authorization for Incontinence Supplies through Medicaid?

If you or someone you know would like to get incontinence supplies through Medicaid, your state insurance plan may require a prior authorization. Obtaining prior authorization is simply an extra step before you can get incontinence products covered by insurance. We’ve outlined below how to get prior authorization for incontinence supplies.

Step 1: Schedule an Appointment with a Physician 

In order to get incontinence supplies covered by Medicaid, you must be examined by a physician and receive a diagnosis for incontinence, also known as loss of bladder or bowel control. Alternatively, you may have a pre-existing medical condition that results in incontinence.

Step 2: Obtain a Signed Prescription for Incontinence Supplies 

During your appointment, be sure to tell your doctor the symptoms you’ve been experiencing. After receiving a medical diagnosis for incontinence, you must ask your physician to provide a signed prescription with information stating that incontinence supplies are medically necessary. 

The prescription must include the following:

• Recipient’s name, 
• full name, address and telephone number of the prescribing provider, 
• diagnosis name and ICD-10-CM code specific to the medical condition/diagnosis causing incontinence, 
• diagnosis name and ICD-10-CM code specific to the type of incontinence for which the supply is required, 
• supply description or product type, 
• anticipated frequency of use, and 
• the quantity to be dispensed

Quantity limits and coverage will depend on your state’s Medicaid guidelines.

Step 3: Find a Medical Supply Provider That Accepts Medicaid 

While you are waiting for your appointment, use this time to do some research and get familiar with the different types of incontinence products available. Durable medical equipment (DME) suppliers, pharmacies, and online retailers may carry different brands of incontinence supplies. It is best to call the provider and ask which incontinence products are covered by Medicaid. 

Step 4: Tell Your Physician to Submit a Prior Authorization Request (If Necessary)

Your physician can submit a prior authorization request to your Medicaid provider either online, on the phone, via fax, or email. They must provide all necessary documentation and answer any questions a Medicaid representative may ask. Requests must be received before the incontinence supplies are dispensed.

A physician and/or healthcare provider may be required to provide documentation such as Incontinence Supplies Medical Necessity Certification along with the authorization request. Information regarding the medical necessity of incontinence supplies must be provided, including the patient’s medical diagnosis, type of supplies needed, and duration of treatment. 

Most Medicaid plans will have a predetermined quantity amount and monthly dollar limit for incontinence supplies that insurance will cover. In some states, prior authorization is not necessary – if the amount of incontinence supplies dispensed does not exceed the set limits and if supplies have been determined by a physician as medically necessary to treat a patient’s condition. 

The criteria for prior authorization depends on the state’s Medicaid program. Some state Medicaid plans may require a prior authorization for the following reasons:

• Recipient requires more incontinence supplies and exceeds the normal quantity limits,
• Recipient’s incontinence condition is temporary and/or when there is no underlying pathologic condition causing incontinence,
• Recipient resides in an Intermediate Care Facility for the Developmentally Disabled-Habilitative (ICF/DD-H) or Intermediate Care Facility for the Developmentally Disabled-Nursing (ICF/DD-N), 
• An incontinence product has a billing code that requires authorization for coverage. 

Step 5: Check If Your Prior Authorization Request Has Been Approved

Follow up with your Medicaid representative or check your account online to see if your prior authorization request has been approved. If the request has not been approved, you may need to call your physician and ask them to resubmit the request with additional documentation (if required). Incomplete prior authorization requests will not be approved, so make sure to include all the necessary documentation. 

Step 6: Contact Your Medical Supply Provider & Order Your Incontinence Supplies

Call or visit your local medical supply provider with your prescription and prior authorization on-hand. They will be able to dispense the requested incontinence supplies at no cost or low copayment, depending on your insurance coverage.

San Pablo Commercial is a family-owned, small business with a mission to deliver affordable medical supplies to their customers. We offer a variety of incontinence products including SPC underpads, adult diapers, disposable bed pads for incontinence, incontinence briefs, and more. SPC disposable quilted underpads are also available on Amazon. We care deeply about our customers and want to make ordering incontinence supplies easier so that they can spend less time cleaning up spills and messes.