OJS Health Care Medical Policies and Clinical Utilization Management (UM) Guidelines

1. Purpose

To establish clear policies and guidelines for the appropriate use of medical equipment and supplies provided by OJS Health Care, ensuring compliance with legal standards and optimizing patient care.

2. Scope

These policies apply to:

Patients and caregivers utilizing OJS Health Care products
Healthcare providers prescribing or recommending OJS Health Care equipment
OJS Health Care staff responsible for product distribution, utilization review, and patient support.

3. Legal and Regulatory Compliance

OJS Health Care adheres to:

Centers for Medicare & Medicaid Services (CMS) guidelines
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) standards
HIPAA regulations for data privacy and security.
State-specific requirements for medical equipment suppliers.

4. Key Components

4.1 Medical Necessity Criteria

OJS Health Care provides equipment and supplies that meet the following criteria:

Prescribed by a licensed healthcare provider.
Necessary for the treatment, diagnosis, or prevention of a medical condition.
Suitable for the patient’s home or care environment.
In line with evidence-based medical guidelines

4.2 Pre-Authorization and Prior Approval

Certain high-cost or specialized equipment may require pre-authorization, including:

Mobility Aids: Power wheelchairs, scooters
Hospital Beds: Adjustable and bariatric models
Compression Stockings: Custom-fitted or prescription-grade.
Lymphedema Pumps: Advanced models for chronic conditions.

Pre-authorization ensures compliance with medical necessity standards:

Urgent Requests: Approval within 72 hours.
Standard Requests: Approval within 14 days.

4.3 Covered Products and Services

The following product categories are subject to medical policy review:

Mobility Aids: Scooters, walkers, rollators, lift chairs
Medical Equipment: Hospital beds, glucose monitors, braces (knee, back, neck, etc.).
Compression Therapy: Stockings and lymphedema pumps
Other Assistive Devices: Walking canes, transfer boards, and accessories.

4.4 Non-Covered Items

The following may not be covered unless specifically authorized:

Equipment for non-medical purposes or general convenience
Duplicate devices unless medically justified.
Repairs or replacements due to misuse.

5. Clinical Utilization Management (UM) Process

5.1 Initial Review

Eligibility Verification: Confirm patient eligibility based on insurance and medical necessity documentation.
Clinical Review: Conducted by trained staff to ensure alignment with medical policies.

5.2 Ongoing Review

For rental or long-term use items (e.g., hospital beds, mobility scooters):

Periodic evaluations are conducted to ensure continued medical necessity.

5.3 Retrospective Review

Evaluation of past services or equipment usage to assess adherence to policy and medical necessity

6. Documentation Requirements

For all equipment and supplies, the following must be submitted:

Physician’s Order: Including diagnosis and justification for equipment.
Patient Records: Supporting clinical documentation.
Proof of Delivery: Verification of equipment receipt by the patient.

7. Confidentiality and Data Security

Patient information is handled in compliance with HIPAA
All data related to UM reviews, patient interactions, and equipment usage is securely stored.

8. Appeals and Grievances

Patients or providers may appeal decisions regarding denied services or equipment:

Internal Appeals: Reviewed within 30 days.
External Appeals: Independent review if internal appeal is denied.

For urgent needs, appeals are expedited, with decisions rendered within 72 hours

9. Product Education and Training

OJS Health Care ensures patients and caregivers receive:

Comprehensive training on the safe and effective use of medical equipment
Access to instructional materials, including manuals and videos.

10. Quality Assurance and Oversight

Regular audits of UM decisions and adherence to medical policies.
Annual review of policies to incorporate new clinical evidence and regulatory updates.

11. Customer Support

OJS Health Care provides:

Ongoing support via phone or in-person consultations.
Assistance with equipment maintenance, troubleshooting, and replacement.