Alberta Health. Alberta Aids to Daily Living Custom-Made Footwear Benefits Policy & Procedures Manual

Transcription

1 Alberta Health Alberta Aids to Daily Living Custom-Made Footwear Benefits Policy & s Manual August 1, 2013

2 Revision History Description Date Update Manual August 1, 2013 Policy F-01: Update Policy August 1, 2013 Policy F-02: Update Policy August 1, 2013 Policy F-03: Update Policy August 1, 2013 Policy F-06: Update Policy August 1, 2013 Policy F-07: Update Policy August 1, 2013 Policy F-10: Update Policy August 1, 2013 Policy F-11: Update Policy August 1, 2013 Policy F-14: New August 1, Government of Alberta 2

3 Table of Contents Policy F Custom-Made Footwear Benefits Background Policy F Process for Obtaining Custom-Made Footwear Benefits Process for Obtaining Custom-Made Footwear Benefits... 7 Policy F Eligibility Criteria for Custom-Made Footwear Benefits Policy F Diagnostic Coding Policy F Choice of Custom-Made Footwear Specialty Supplier Policy F Custom-Made Footwear Quantity and Frequency Limits Policy F Changing Custom-Made Footwear Providers Policy F Service Dates Policy F Statement of Account Policy F Custom-Made Footwear Suppliers Qualifications Policy F Custom-Made Footwear Specialty Suppliers Roles and Responsibilities Government of Alberta 3

4 Policy F Custom-Made Footwear Client Roles and Responsibilities Policy F Approved Custom-Made Footwear Specialty Supplier List Policy F Validation Certificate Government of Alberta 4

5 Policy F 01 Custom-Made Footwear Benefits Background 1. Clients must meet general AADL criteria and specific clinical eligibility criteria for AADL Custom-Made Footwear. 2. AADL Custom-Made Footwear benefits available to eligible clients include: Custom-Made Footwear for 1 st Degree Deformity, 2 nd Degree Deformity, and 3 rd Degree Deformity. Partial Foot Replacements Government of Alberta 5

6 Policy F - 02 Process for Obtaining Custom-Made Footwear Benefits Clients and Custom-Made Footwear providers will follow the AADL procedure for obtaining and providing Custom-Made Footwear benefits. Clients: 1. Follow process outlined on page 7 of this policy. Specialty Suppliers: 1. Follow process outlined on page 7 of this policy Government of Alberta 6

7 Process for Obtaining Custom-Made Footwear Benefits 2013 Government of Alberta 7

8 Policy F - 03 Eligibility Criteria for Custom-Made Footwear Benefits 1. Clients must meet the general AADL eligibility criteria and have: A structural bony deformity of the foot such as with talipes equino varus, severe arthritis and resultant deformity, or neurological damage to the foot with resultant deformity or stablilized gross edema. If clients cannot wear a modified, or special off-the-shelf shoe for these reasons, they are eligible for this benefit. Clients must be ambulatory. A physician who is a member in good standing of the College of Physicians and Surgeons of Alberta must prescribe Custom-Made Footwear. A generic prescription from a physician stating: a) Specific benefit requested, and b) Other information related to foot problems and/or specific instructions. 2. AADL does not provide Custom-Made Footwear benefits for: Non-ambulatory clients. Clients only able to pivot and/or stand for transfers. Clients who refuse to try off-the-shelf footwear. Edema management. Post-operative conditions. Exclusive use for sports, recreation or rehabilitation purposes. 3. AADL does not provide Custom-Made Footwear for clients having problems finding the appropriate off-the-shelf footwear because they have oversized, or undersized feet, extra width/depth needs, a split size requirement, problems with edema, lesions or acute postoperative conditions. 4. A leg length discrepancy indicates a need for a shoe elevation, and not Custom-Made Footwear. 5. It is recognized that some orthotic devices (such as Ankle Foot Orthosis) may cause fitting problems, but this does not indicate a need for Custom-Made Footwear. 6. Clients are eligible for one pair of Custom-Made Footwear every year based on clinical need Government of Alberta 8

9 Clients: 1. Obtain a prescription from a physician. 2. Contact the AADL Program for a list of specialty suppliers. Vendor lists are available on the AADL website at 3. Must try off-the-shelf footwear such as extra width, extra depth before being deemed eligible for Custom-Made Footwear. Specialty Suppliers: 1. Confirm client eligibility. 2. In cases of ineligibility, may suggest alternate footwear options. 3. Obtain physician s prescription from client. 4. Enter authorization on E-Business. 5. Complete all required assessment documentation Government of Alberta 9

10 Policy F - 04 Diagnostic Coding Diagnostic coding must be provided to assist in determining client eligibility for benefits. Specialty Suppliers: 1. Indicate the exact diagnostic code on the AADL E-business authorization form. Choices are listed in the drop down box on the AADL E-business Create/Maintain authorization screen. 2. If Other is used, must indicate the specific diagnosis in the AADL E-business Client Benefit note Government of Alberta 10

11 Policy F 05 Choice of Custom-Made Footwear Specialty Supplier Clients have a choice of specialty supplier. Clients: 1. Select a specialty supplier from the AADL approved Custom-Made Footwear Vendor list. AADL: 1. Maintains a list of AADL approved Custom-Made Footwear Specialty Suppliers that authorizers and clients may access for Custom-Made Footwear information and services Government of Alberta 11

12 Policy F 06 Custom-Made Footwear Quantity and Frequency Limits 1. Clients are eligible to receive Custom-Made Footwear benefits per the quantity and frequency listed on the AADL Approved Product List Custom-Made Footwear Benefits. 2. Clients are eligible for one pair of Custom-Made Footwear every twelve months. 3. AADL recognizes that some clients may prefer to have two pairs of Custom-Made Footwear at one time to accommodate for different seasons or environments. As AADL does not provide duplicate benefits, clients may elect to receive a future pair of footwear early. Therefore a client may receive two pairs of footwear in the first year and no additional pairs in the second year. This is not considered over-quantity and therefore a Quantity and Frequency Review request QFR is not necessary. For Clients who have chosen the early second pair of footwear, further early replacement (third or fourth pair in the two-year period) will only be considered by a Quantity and Frequency Review Request that clearly demonstrates a significant change in clinical condition. AADL will not provide additional footwear (third or fourth pair in the two-year period) if the original two pairs of footwear are worn out within the two-year period. Clients: 1. If clients elect to receive a second pair of footwear early, must acknowledge the increase in frequency of eligibility for replacement from one year to two years. 2. Follow the Quantity and Frequency Review (QFR) process as outlined in the general AADL Program Manual for situations of significant change in condition. 3. Are responsible for the cost of the footwear if the QFR is denied. Specialty suppliers: 1. Confirm client consumption on the AADL E-business PHN Inquiry screen. 2. Advise client of quantity and frequency limits. 3. Documentation procedure: a. If it is over one year since the client was provided with a similar benefit and the client has not chosen an early second pair of Custom-Made Footwear, document the quantitative rationale for replacement on the AADL E-Business Client Benefit Note screen. b. If it is prior to the one year period since the client was provided with a similar benefit, follow the QFR process as outlined in the General AADL Program Manual Government of Alberta 12

13 c. If the client elects to receive a second pair of Custom-Made Footwear early, inform AADL Program Benefit Clerk who will update the AADL system. Do not submit a QFR. This is not considered additional quantity or frequency of the benefit. The new eligibility date for replacement of the Custom-Made Footwear will be two years from the service date of the first pair of Custom-Made Footwear. Ensure the Validation Certificate for the second pair of footwear states 2 years for eligibility for replacement when the client signs the third section. Example: Aug 1, 2013: Client receives first pair of Custom-Made Footwear Date client is eligible for replacement: Aug 1, 2014 Client elects to receive second pair of Custom-Made Footwear early Oct 15, 2013: Client receives second pair of Custom-Made Footwear Date client is eligible for replacement: Aug 1, Government of Alberta 13

14 Policy F 07 Changing Custom-Made Footwear Providers Clients must be attended by only one Custom-Made Footwear provider at a time. Clients must not switch providers during the fabrication process of Custom-Made Footwear, unless prior approval is given by AADL. Clients: 1. Responsible for giving current provider the opportunity to provide footwear that meets the client s needs. 2. Contact the AADL Program Manager regarding concerns on service or device. 3. Submit a formal AADL Complaint if applicable. Custom-Made Footwear Specialty Suppliers: 1. Check E-Business to verify if client has been provided Custom-Made Footwear benefits by AADL. If yes, contact AADL benefit clerk to find out who was the previous Custom-Made Footwear Specialty Supplier. 2. Refer client back to original service provider for ongoing service and follow-up with footwear benefits. a. If client refuses to return to previous Specialty Supplier, the provider must not provide service to the client unless the client is willing to fund the services privately. b. If a client is eligible for replacement, see point May choose to contact previous Specialty Supplier to discuss transferring care to the new Custom-Made Footwear povider. a. Advise AADL Program Manager if agreement of a transfer of care is reached. 4. Do not submit a Quantity and Frequency Review for a request to switch Specialty Supplier. 5. Advise the client to submit a formal AADL Complaint if applicable Contact AADL Program Manager for advice as required Government of Alberta 14

15 AADL: 1. Reviews client s concerns via formal complaint process. 2. Refers client to a multidisciplinary team for assessment if available. 3. Recommends change of Specialty Supplier if appropriate. 4. Takes a credit on Custom-Made Footwear that has been determined not to be appropriate for the client Government of Alberta 15

16 Policy F 08 Service Dates The service date used for submitting claims for Custom-Made Footwear is the date the client signs the final section of the Custom-Made Footwear Validation Certificate. Custom-Made Footwear Specialty Suppliers: 1. Indicate the service date on the claim according to the date the client received the benefit Government of Alberta 16

17 Policy F 09 Statement of Account Specialty Suppliers must provide every client with a Statement of Account for each benefit invoiced to the AADL Program. The Statement of Account must include the AADL contribution and cost-share portion of each benefit (when applicable). Custom-Made Footwear Specialty Suppliers: 1. Provide client with a Statement of Account for AADL benefits when invoiced to the AADL Program. 2. For cost-share clients, identify the AADL contribution and the client s cost-share contribution for each benefit. 3. For cost-share exempt clients, identify AADL s contribution for each benefit. 4. Retain a copy of Statement of Account on client file. AADL 1. Conducts audits to identify discrepancies of costs between the claims received and the Statement of Account received by the client Government of Alberta 17

18 Policy F 10 Custom-Made Footwear Suppliers Qualifications 1. The provider of Custom-Made Footwear benefits must be one of the following: a. To provide Custom-Made Footwear benefits, including the manufacturing of Custom- Made Footwear the provider must be a Certified Pedorthic Master Craftsman in good standing with the College of Pedorthics of Canada. b. To provide Custom-Made Footwear, excluding the manufacturing of Custom-Made Footwear the provider must be one of the following: i. Certified Pedorthist in good standing with the College of Pedorthics of Canada. ii. Certified Orthotist in good standing with the Canadian Board for Certification of Prosthetists and Orthotsits. 2. The provider must be employed by a facility with an agreement with AADL to provide Custom-Made Footwear benefits. Custom-Made Footwear Specialty Suppliers: 1. Notify AADL when changing employment location. AADL: 1. Verifies membership with appropriate professional certification body. 2. Provides a Specialty Assessor number. 3. Updates employment location information Government of Alberta 18

19 Policy F 11 Custom-Made Footwear Specialty Suppliers Roles and Responsibilities Custom-Made Footwear Specialty Suppliers assess and fit clients for Custom-Made Footwear benefits and services. A Certified Pedorthist or a Certified Orthotist is able to provide the following for AADL clients: Assessment for Custom-Made Footwear. Casting and measuring for Custom-Made Footwear. Fitting of Custom-Made Footwear. A Certified Pedorthic Master Craftsman is able to provide the following for AADL clients: Assessment for Custom-Made Footwear. Casting and measuring for Custom-Made Footwear. Manufacturing Custom-Made Footwear - including: Measuring, casting and making original shoe lasts; Designing and making upper patterns; Manufacturing fitting model of shoes; and, Lasting and finishing of custom shoes. Fitting of Custom-Made Footwear. Custom-Made Footwear Specialty Suppliers: 1. Assess clients who have a structural bony deformity of the foot such as with talipes equino varus, severe arthritis and resultant deformity, or neurological damage to the foot with resultant deformity or stabilized gross edema. 2. Ensure: Clients cannot wear a modified or special off-the-shelf shoe (clients must try off the shelf shoe such as an extra width, extra depth prior to determining eligibility for this benefit) Government of Alberta 19

20 Clients are ambulatory. Clients meet the Custom-Made Footwear benefit eligibility criteria. Clients are advised of their responsibilities related to program benefits including the expiry date of their Custom-Made Footwear authorization. Clients sign the Client Declaration form. 3. Accept only a generic physician prescription. 4. Contact the AADL Custom-Made Footwear clerk and/or the Manager with concerns, questions, prior approvals, and unusual requests. If eligibility is questionable, an authorization is not to be completed. 5. Complete the on-line authorization as outlined in the On-Line Training Manual within 20 business days of the assessment. 6. Retain on file: Authorizations Assessments Physician s Generic Prescription Pedograph Photograph Custom-Made Footwear Criteria Document A and B Documentation, including provider signature, of all AADL client encounters 7. Adhere to the AADL Specialty Supplier Agreement and both the general AADL and Custom-Made Footwear Policies and s. 8. Honour manufacturer s warranties. 9. Ensure that a Certified Pedorthic Master Craftsman approves the end product of each stage of fabrication of Custom-Made Footwear: casting last making pattern making upper making lasting finishing 10. Provide instructions to Clients on the care, operation and maintenance of any Custom-Made Footwear 11. Use all reasonable efforts to supply the Custom-Made Footwear at the lowest possible cost. 12. Provide clients with a statement of claim indicating AADL s portion and the client s portion if applicable. 13. Inform the client that he or she is responsible for all repairs to their Custom-Made Footwear Government of Alberta 20

21 14. Provide appropriate follow-up. AADL: 1. Ensures Specialty Supplier complies with roles, responsibilities and contractual obligations. 2. Conducts post-audit reviews Government of Alberta 21

22 Policy F 12 Custom-Made Footwear Client Roles and Responsibilities Clients receiving Custom-Made Footwear benefits shall meet the current AADL Custom-Made Footwear eligibility criteria for the benefits they are receiving and must comply with AADL policies and procedures. Clients: 1. Provide the Specialty Supplier with a generic physician s prescription. 2. Are aware that if off-the-shelf footwear such as extra width, extra depth will meet their clinical needs they are not eligible for Custom-Made Footwear and aware that this alternative must be trialed prior to Specialty Supplier determining eligibility for Custom-Made Footwear. 3. Are aware that Custom-Made Footwear provided by AADL is for function not for cosmetics. 4. Are aware that it is their responsibility to repair and maintain their Custom-Made Footwear. Clients are eligible for two pairs of Custom-Made Footwear per two year period; replacements are based on need as determined by the Specialty Supplier. 5. Are aware that AADL does not provide early replacement of lost, stolen or damaged Custom-Made Footwear. 6. Are aware that AADL will assist with replacement of worn Custom-Made Footwear only when it is no longer economically feasible or safe to repair, or when there is a significant change in their foot condition. This requires a Quantity and Frequency Review (QFR) request. 7. Comply with Specialty Supplier policies regarding abuse-free facility environments. Failure to comply may result in the supplier declining further services Government of Alberta 22

23 Policy F 13 Approved Custom-Made Footwear Specialty Supplier List AADL will only provide funding to eligible clients who receive their benefits from the Approved List of Custom-Made Footwear Vendors. Clients: 1. Select a Specialty Supplier from the current Custom-Made Footwear Vendor list available upon request or on the AADL website. AADL: 1. Provides clients with information in writing upon request, or refers to AADL website. 3. Maintains list of approved Specialty Suppliers Government of Alberta 23

24 Policy F 14 Validation Certificate The Validation Certificate is a document intended to ensure accountability and clarify expectations for all parties involved in the provision of Custom-Made Footwear. The Validation Certificate is a three part form, in that the client will sign this form on three separate occasions: 1. At time of assessment: acknowledging agreement to the type of footwear being provided. 2. During fabrication of device: acknowledging receipt of footwear. 3. After final provision of the device: acknowledging satisfactory fit and function of footwear. The AADL Program Manager should be contacted if the client refuses or feels they are unable to sign the form. Specialty Suppliers: 1. Discuss footwear to be provided and ensure client understands their responsibilities. 2. Have client sign first section of Validation Certificate prior to starting fabricating the footwear. a. Provide client with a copy of the Validation Certificate if requested and retain the original on the client s file. 3. Upon providing footwear to the client to trial, have the client sign the second section of the Validation Certificate to confirm receipt. 4. Once the device is completed and the final fitting complete, the client must sign the Validation Certificate to confirm satisfactory fit and function of the footwear. a. The client should be provided with a reasonable length of time to trial the footwear prior to being asked to sign the Validation Certificate. For some clients, the trial period may be very short. A client may be able to sign both the second and third sections on the same day. b. The client should only sign once all concerns are addressed Government of Alberta 24

25 c. The Specialty Supplier should not submit a claim for the footwear until the last section of the Validation Certificate is signed by the client, which is considered the service date for the footwear. d. If the client fails to return for the final fitting or refuses to sign the final section of the Validation Certificate, the Specialty Supplier may claim for a portion of the cost of the footwear as follows: Provide AADL with a copy of the Validation Certificate signed in first two sections. Provide evidence of attempts to resolve issues or contact client for follow-up. Provide catalogue numbers and cost for unclaimed items to AADL. AADL will provide billable amount. e. Clients who are unable to return for follow-up may sign and submit the final section of the Validation Certificate by alternate methods (i.e., fax or mail). Clients: 1. Fully read and understand the Validation Certificate prior to signing it. 2. Contact the AADL Program Manager if they are unable to sign the Validation Certificate. AADL: 1. Responds to questions and concerns from Specialty Suppliers or clients regarding the Validation Certificate. 2. May request copies of the completed Validation Certificates. 3. Reviews cases of client refusal to sign Validation Certificate Government of Alberta 25