Health Services

Electronic Invoice Submission

Training Guide

November 2019

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TABLE OF CONTENTS

1. Important notes ………………………………………………………………………………………………………………………………………………….. 3 2. Health Services E-Form: How to prepare an Invoice • General Overview (Invoice breakdown) ……………………………………………………………………………………………………………… 4 o Section A: Document Type, Program, Vendor Reference, Card expiry date ...……………………………………………………….. 5 o Section B: Client Information, Vendor Information ………………………………………………………………………………………. 6 o Section C: Billing Section Itemised list ………………….………………………………………………………………………………... 9 Search Feature ……………………………………………………………………………………………………………………. 10 Service Dates, QTY ...……………………………………………………………………………………………………………. 11 Unit, Category ………..…………………………………………………………………………………………………………… 12 Product Type, Eligible services …………………………………………………………………………………………………. 13 Additional details, AAC (Wholesale Acquisition Cost), Retail prices ………………………………………………………… 14 Tax (Drop down box) ……………………………………………………………………………………………………………… 15 Subtotal, HST and Total ………………………………………………………………………………………………………….. 16 o IMPORTANT: Why are my totals not showing up? ….………………………………………………………………………………. 17 o Section D: Additional Information ………………………………………………………………………………………………………….. 19 o Section E: Saving the form 20 Button Feature (Red and Green messages) …..………………………………………………………………………………. 20 Saved location .……………………………………………………………………………………………………………………. 21 o Section F: Status of Request, Approval Start Date, Approval End Date and Approval number …………………………………….. 25 o Section G: Estimate submission, Payment submission, File name features ………………………………………………………….. 26 3. Who to Contact: • Training, Password Reset for Watchdox, OS, TN, RS and MS Administrator contact information …..……………………………………….. 27 4. Annexes – Invoice examples 28 o Annex A – Ostomy / Incontinence Estimate Request ……………………………………………………………………………………. 29 o Annex B – Ostomy / Incontinence Invoice Request ……………………………………………………………………………………… 30 o Annex C – Therapeutic Nutrient (Oral Supplements) Estimate Request .……………………………………………………………... 31 o Annex D – Therapeutic Nutrients (Oral Supplements) Approval ……………………………………………………………………….. 32 o Annex E – Therapeutic Nutrients (Oral Supplements) Invoice …………………………………………………………………………. 33 o Annex F – Therapeutic Nutrient Hyperalimentation Invoice …………………………………………………………………………….. 34 o Annex G – Breathing Aids, Invoice ………………………………………………………………………………………………………… 35 o Annex H – Medical Supplies, Invoice ……………………………………………………………………………………………………… 36 Annexes – Search list for the E-form ………………………………………………………………………………………………………………………… 37

3 IMPORTANT NOTES 1. When you first open the claim, you will notice a yellow message at the top of the form. You must enable macros and enable editing and say Yes to the prompt of adding this to your Trusted Documents.

2. Yellow fields on the Health Services E-form are always mandatory. Other fields may also be mandatory, depending on the request, and if the information is missing, the request will be returned for proper completion. For fields which are not yellow, simply click in the appropriate space. If the space is light blue, this is an indication that it is a dropdown menu and you should see a small arrow appear at the right of the selected cell. Click on that arrow to activate the drop-down menus.

If the cell is white after clicking in it, it means that it is a FREEFORM cell, meaning you can type relevant information. . 3. You can use the “Tab” button on your keyboard to move left to right between yellow fields on this form and use your arrows up ↑ and down ↓ on your keyboard to select the fields below and above. 4. To break lines in certain fields, such as addresses, additional information or comments sections, use ALT+ENTER to break paragraphs. CAN I E-MAIL THE E-FORMS? Due to strict client privacy and confidentiality policies, vendors cannot e-mail the E-form to Health Services. You must print or upload the file in Watchdox once it is completed. Estimates/Quotes: Once completed via the computer, you can print the e-form and fax as per the norm to 1-506-453-3960 or upload the e-form to Watchdox. Invoices: Once completed and your payment requests adhere to Health Services approval / payment policy, please upload the document to Watchdox or print the document and mail it to:

Social Development Health Services Unit

PO Box 5500 Fredericton NB, E3B 5G4

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HOW TO PREPARE A HEALTH SERVICES INVOICE Invoice breakdown

Section A

Section D

Section C

Section B

Section F Section E

Section G

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SECTION A

Document Type (Drop Down Box) This is used to identify what type of document you are requesting with a drop-down menu. When clicking on the yellow field, a drop-down menu will appear that includes the options “Cost estimate” or “Request for payment”. Select the appropriate one according to your request. If you are submitting for payment, select “Request for payment” and if you are submitting a request for approval, select “Cost estimate”.

Program (Drop Down Box) This is to identify which program your request fits in. It is important to identify the correct program so that the correct codes, mark-up percentage and tax options appear correctly on the form. When clicking on the yellow field, a drop-down menu will appear that includes the options: Ostomy / Incontinence (OS), Breathing Aids - Pharmacy (OX), Therapeutic Nutrients (TN), Medical Supplies – Pharmacy (MS).

Reference Number (Free form) This is used to identify your invoice once payment is issued by Health Services. Click on the yellow field to access the cell and you will notice that this is free form, meaning you can type whatever you wish. This number will appear in red.

IMPORTANT: Do not use a forward ( / ) or backward ( \ ) slash in this area. This will interfere with the save feature of the E-Form. This number is mandatory as it identifies your payment on the cheque stub provided by Social development. It can be any combination of letters and digits (!@#$%^&*) with up to a maximum of 20 characters. If you go past the character limit, there will be an error prompted for you to try again.

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SECTION B

Client Information This area is used to provide the client’s Health Card Number (Identification Number), their name, address, the client’s date of birth and the health card expiry date. All yellow fields are mandatory. Client Identification Number (Free form, mandatory) This area is used to provide the client’s Health Card Identification Number. Do not use the client’s Medicare number. Click inside the blank yellow field beside the words “Health Card Identification Number”. This field requires a total of 9 digits, including the letter located at the end of the number. The letter at the end only applies to identification numbers that begin with 6, 8 or 9. Identification numbers that begin with 0 do not have this letter. There will be an error message prompted if the 9 digits are not entered correctly. Please note that there is NO letter at the start of the health card number.

• Special Care Homes Clients: 92314567A • Mental Health Cards: 96345678A • Nursing Homes Clients: 81245678R • Child and Youth Services Clients: 60123456C • Social Assistance Clients: 000012345

Card Expiry Date (Free form, mandatory) This area is used for the client’s health card expiry date. The date format should follow DAY, MONTH and YEAR

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Name of client (Free form, mandatory) This area is used for the client’s name indicated on the health card. Click on the field beside the words “Name of client” (yellow section). Please refrain from using other names that the client may provide and only use the name on the health card. If the client name does not match the health card, there could be a delay or refusal in processing your payment request as we will have to verify the information. Address (Free form, mandatory) This area is used for the client’s current known address. Click on the field beside the word “Address” (yellow section). You will need to press ALT + ENTER to break your lines for the address. Date of Birth (Free form, mandatory) This area is used for the client’s date of birth. The date format should follow Day, Month, Year: 31-08-2019 Vendor Information This area is used to provide the Vendor’s billing and contact information. All yellow fields are mandatory.

Vendor Identification Number (Free form, mandatory) This area is used to provide the vendor’s identification number. Click on the field beside the words “Vendor Identification Number” (yellow section). This number is used to process payments and is mandatory. This field requires a total of 8 digits, Including the possible letter V at the beginning. Please note that the V is not in all vendor numbers, only a select few. There will be an error message prompted if the 8 digits are not entered correctly.

• V1234567 • 61234567 • 71234567

Vendor Name (Free form, mandatory) This area is used for the vendor’s business name. Click on the field beside the words “Vendor Name” (yellow section). Please ensure to type the correct name of the business or the correct vendor’s name.

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Vendor Address (Free form, mandatory) This area is used for the vendor’s current address. Click on the field beside the word “Address” (yellow section). You will see that you will need to press ALT + ENTER to break your lines for the address.

Vendor Telephone Number, Fax number This area is used to provide the Vendor’s telephone and fax number in case Health Services needs to contact you about an issue with the form sent in. Click on the field beside the word “Telephone Number” (yellow section).

Vendor E-mail (Free form) This is to help Health Services have up-to-date e-mail contact information in case Health Services needs to contact you about an issue with the form sent in. Click on the field beside the word “E-mail (yellow section). SAVING YOUR VENDOR INFORMATION You can save your vendor information on the blank version of the form so that you can avoid having to re-type it every time you open the document.

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SECTION C

Itemised Section for billing or estimates (See Annexes for full examples) This area is used to list the items requested for a prior approval or has been authorized to purchase through Health Services.

Name Description Format Search for service Search for services (ie: Wafers, Aerochamber, Supplement, Tube feeding) Dropdown, Free form Date The date entered is the date the client physically picked up the items. 30-JUN-2018, 30-06-2018 QTY The number of full packages, boxes, units you are providing for this billing cycle Numerical UNIT The number of units in 1 package / box. Numerical Category Identify the category - i.e. Colostomy, Intermittent caths, Dietary supplement, etc. Depends on PROGRAM Free Form Product Drop Down Box – Dependable on “Category”. Only shows available products linked to chosen category. Drop down list Eligible Service Drop Down Box – Dependable on “Product”. Only shows eligible services. Drop down Additional details Brand name of the product and reference number if applicable (IE: Hollister Wafers #401210, Ensure Strawberry) Free form Code This code is populated from the “Product” drop down. Locked. Auto-completes CT Health Services – Depends on the “Product” drop down, codes that are taxable / non-taxable. Locked. Auto-completes AAC Wholesale acquisition cost. Please enter the cost for 1 pack / 1 box / 1 unit depending on the program. Numerical Retail Your shelf price to in-store customers. Numerical % Mark-up. The percentage approved via the agreement that came into effect August 1 2016. Locked. Auto-completes Return Once the form has compared the AAC+% vs Retail, it will show the reimbursement for 1 QTY. Locked. Auto-completes T Tax. Drop Down – If the item is taxable, choose “Y”, if non-taxable, choose “N”. Drop down list Subtotal QTY x RETURN will provide the subtotal Locked. Auto-completes HST Dependable on CT and T areas. Locked. Auto-completes Total SUBTOTAL + HST added together to provide the total. Locked. Auto-completes

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Search for services (Drop-down, searchable with limited free form)

This section is meant to help you search services that are approved with Health Services. You can do a partial search (i.e. tub for tubes, water for water) or use the drop-down menu for the full list. To activate the drop-down menu, click on the cell that shows “Type here to search” and press “Delete” on your keyboard, this will allow the drop down to work. Here is an example when you click in the blue cell and press the arrow without typing in a partial word search. The full list of equipment and services will drop down. This can be a little difficult to find a service quickly.

For a partial word search, type the word and press ENTER. Once you’ve hit enter, you can select the cell again and press on the drop-down arrow to see what the list offers. Choose the item you want

The results of the search are arranged in the following order: CATEGORY, PRODUCT and ELIGIBLE SERVICE. This is to help you quickly choose the right drop downs in the invoice area.

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Service Dates (Mandatory for payment request only) When selecting “Invoice for payment”, the Service date field will light up yellow, to indicate that this field is mandatory. The date format is DD/MM/YYYY (30-06-2019).

The service date field will remain WHITE if you choose “COST ESTIMATE” as it is not a required field. You will notice that the QTY field will then light up yellow once you fill the service date, to help guide you through the next mandatory field. QTY (Quantity) When entering the date, or setting the form to “Cost estimate” the QTY field will light up yellow. This indicates the number of boxes, packages or units provided to the client during this billing cycle. IE: If you have 14 packages of diapers, you would put in 14 in QTY. If you have 8 packages of ensure, you would put 8 in QTY. If you have 1 spacing device (Aerrochamber / Optichamber), you would put 1 in QTY. If you have 1 pair of compression stockings, you would indicate 1 under QTY.

You will notice that the UNIT field will then light up yellow, to help guide you through the next mandatory field.

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UNIT This is where you would indicate how many units are in a single package provided. Health Services policies are dictated by quantity maximums and it is vital that this information is provided in ESTIMATES and in INVOICES. If this information is not provided correctly, Health Services will return the invoice to you for correction. IE: If you provided 14 packages of 28 diapers, you would type in 28 in the UNIT field as there is only 28 units of diapers in 1 package. If you provided 10 packages of 6 ensure, you would enter 6 in the UNIT field as there are 6 UNITS of ensure bottles in 1 package If you provided 1 spacing device, you would enter 1 in UNIT as there is only 1 spacing device in the package. If you provided 1 pr of compression stockings, you would enter 1 in the UNIT field as there is only 1 pair per package.

Once the UNIT field is filled, you will notice that the Product Detail field will light up yellow to help guide you through the next mandatory field. Category (Drop-down) This field is reliant on the PROGRAM field, meaning you must choose the appropriate program first before this drop down will work. This is used to narrow down your request for different types of categories, such as Ileostomy, Colostomy, Cecostomy, Incontinence, etc.

In this example, we are looking for diapers. Incontinence.

The next field will now show words “Select…” meaning that these are drop-down menus.

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Product (Drop-down, mandatory) It is important to note that this field is reliant on the “CATEGORY” field and will not function if the category is not picked. Only the products related to the category will appear in the drop down.

Choose the product you are looking for, in this example, we are looking for “Disposable”.

When you choose the product type, you will notice that the ELIGIBLE SERVICES fields will say “Select…” indicating that this is another necessary field that needs to be completed. Eligible Services (Drop down, mandatory) This field relies on “PRODUCT”. If the product field is blank, the drop down will not work. This narrows down the specific service you are requesting.

For this example, we are looking for “Diapers”.

You will notice that the CODE, CT and % areas have automatically completed and that the AAC area has turned YELLOW. I will cover this after “Additional details” is covered.

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Additional details Max 17 characters (Free-form, not mandatory) This field is used to include the brand of the product you are providing and any other information such as reference numbers to order the product, etc. This space is limited on characters, please be very brief.

Here are other examples to follow:

• Tena, XL ABS, • Convatec #159856 • Personelle, LG • Ensure, strawberry • JAMP • 40 strength • Hollister #121416 • Hypafix 10x10

Please do not put in Rx numbers only. AAC – Wholesale acquisition cost (Price of 1 Unit) This is where you enter the wholesale cost (your cost when you purchased your item from your provider) of 1 package. No prices in the RETURN or SUBTOTAL will show since you are still missing your retail price.

Retail – Retail price (Price of 1 unit) This is where you enter the retail price, meaning the price on your shelf.

Now that you have entered the retail price, you will see the RETURN field autopopulate with the final decision on what will be reimbursed for 1 QTY.

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Why is this necessary? The Health Services form will use the AAC+Markup and compare it to your RETAIL and determine which cost is lower and populate its decision in the RETURN field.

Here are examples of the fields when the AAC+% is cheaper than the RETAIL:

Here is an example when the AAC+% is more than the RETAIL:

Once the Retail field is completed, you will notice the TAX field light up bright blue for you to complete. Tax (Drop down, mandatory) The blue Tax field is to confirm if the item requested has tax or no tax. Once this final field is competed, you will see your total for that line.

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Why is the drop down field necessary? Some items are taxable under a code but due to the way it’s processed (through prescription, or store front) it may require to remove the tax manually. It is vital that you choose the correct Product so that the correct SD code appears.

Subtotal, HST and Total (Locked, auto-populated) This is where the RETURN is multiplied by the QTY field. HST will be applied if it is allowed.

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IMPORTANT – Why are my totals not showing? If your totals are not showing, you may not have entered information in the yellow fields or there is information missing in the row. Please review each column in the row and ensure there are no yellow fields visible and then check to see if you’ve entered the reference number. Example: “Missing Vendor Reference” – as a Request for payment

Solution: Fill in the reference number

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Example: “Request for Payment” – No service dates

Solution: Add the date to fix the issue:

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SECTION D

Additional Information – Free form This field is used for additional important information that you feel Health Services needs to consider. If you wish to break your lines while typing, press ALT+Enter. Health Services will also use this area to add information that may be considered important for you to review.

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SECTION E

Button – Save feature (Click to save)

This button is the save feature of the form. When all mandatory fields are completed, the red area around the button will turn green and the message will change to let you know that you can now save the form. The mandatory fields are as follows:

• Document Type • Program • Vendor Reference (No / or \ slashes) • Health Card Number • Health Card Expiry Date • Client Name • Client Address • Client Date of Birth • Vendor Identification Number

• Vendor Identification Number • Vendor Name • Vendor Address • Service Date (Only for invoice, not madatory for Estimates) • QTY • Unit • Product Type • AAC • Retail • Tax drop down

Once all these fields are completed, you will notice the fields turn green:

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When you click the save button, a new pop up will appear, asking you to confirm information:

• Type of request, for what program, your vendor name, your vendor ID, the client name, the client ID, your invoice total and reference number. • If there is information missing, you will see “You have information missing” at the bottom of the pop up and you should review your invoice.

Click on “The information is correct, I want to save” to save your file, or if you need to edit, click on “The information is incorrect, I need to edit.”

If you find that the form will not save, even with the message green, please check your totals. If you see them as 0, check the row and see if there is any yellow. Ensure that there are no forward or backwards slashes in the VENDOR REFERENCE NUMBER. This will cause a problem during the automatic saving process.

If you get an error for the PDF format, do not worry. The form has saved as an Excel document and you can use it for Invoice.

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Saved Location The Click to Save button will save the form located at C:\Users\Public. If you are unable to find this location on your PC, please contact Health Services. The trainer will guide you through the various steps to find this area on your computer. How to find the document:

• Press on the START KEY

• Look for “Computer” in the menu that pops up and click on it.

• This will bring up a list of your hard drives. You are looking for the“C:” drive or “OS” drive.

• Click on the C: drive.

• You will see a list of folders, you are looking for one named “USERS”

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• Double click the folder name “USER” and it will lead you to a new area with more yellow folders. Now you are looking for “PUBLIC”

Before you double click on the file, I recommend that you right click on your mouse to pop up a new menu and choose “Send to desktop” this will create a shortcut to this folder on your computer desktop so you do not have to do this everytime.

• Once you doble click the “PUBLIC” folder, you will find the EXCEL version of the file (estmates) or the Excel and PDF version of the files here:

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If you are unable to find this location on your PC, please contact Health Services. The trainer will guide you through the various steps to find this area on your computer. Estimates will be shown in this folder as EXCEL documents (the names will start with E) while Invoices will show as PDF and EXCEL documents (the names will start with I). These documents can be mailed to Health Services or uploaded into Watchdox if you are using the online system. Please note that Health Services will only accept the Excel documents for Estimates, we will be returning PDF ESTIMATES as we need to edit the information. You may upload the PDF or the EXCEL in Watchdox for payment processing, or if you do not have access to WATCHDOX, send it in the mail. Do not upload both files in Watchdox as it may cause a double billing issue.

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SECTION F

Status of Request – Locked, SD Only This area is used to note the Estimate as APPROVED, REFUSED or PENDING. Approval Start Date – Locked, SD Only This area is used to enter the start date of an approval for the Therapeutic Nutrients program or Ostomy and Incontinence. Approval End Date – Locked SD only This area is used to indicate when the approved services are ending. Once the approval has ended, the client must provide a renewal request. Depending on the program, each policy located on the Health Services website or in Watchdox provides steps for renewal. Approval Number – Locked, SD Only This area is reserved for the approval number once an estimate is approved. This original file should be reused for billing as it counts as the “final” format of the form.

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SECTION G

Estimate Submission – Autofilled This area is stamped with the current date that you use the SAVE BUTTON feature while the document type is under “COST ESTIMATE”. Payment Submitted – Autofilled This area is stamped with the current date that you use the “SAVE BUTTON” feature while the document type is under “REQUEST FOR PAYMENT”. HS Invoice / Estimate File name This is the naming convention for the saving feature. The SAVE FEATURE takes the name from this area. If there is mandatory information missing, the area will be red and say “You are missing information”. Please review your submission.

If the information is correct, you will see this:

The Health Services only has a button inside the field, this is for administrators only.

WHO TO CONTACT

27 For pharmacy and non-pharmacy vendors:

For Health Service E-Form Training, you can contact Alisson Grenon-Bent at (506) 444-2475 between 8:15 am and 4:30 pm and make an appointment for a 30 minute training session.

For pharmacies ONLY:

Please note that E-form training and Watchdox training can take up to minimum 45 minutes over the phone and requires your complete attention without interruption. If you need to have your password reset for Watchdox, do not use the “Password rest” on the website as it does not work due to privacy policy, please e-mail Alisson.grenon-bent@gnb.ca with your e-mail address and a note indicating that you need to have your password reset.

Program Telephone number Ostomy and Incontinence, (506) 444-2475 Therapeutic Nutrients (506) 453-5853 Respiratory Services (506) 453-2573 Medical Supplies and Services (506) 453-6239

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ANNEXES Invoice Examples

Search List

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Annex A – Ostomy / Incontinence Estimate Request

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Annex B – Ostomy / Incontinence Invoice Request

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Annex C – Therapeutic Nutrient (Oral Supplements) Estimate Request

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Annex D – Therapeutic Nutrient (Oral Supplements) Approved

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Annex E – Therapeutic Nutrient (Oral Supplements) Invoice

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Annex F – Therapeutic Nutrient (Hyperalimentation) Invoice

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Annex G – Breathing Aids, Invoice

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Annex H – Medical Supplies, Invoice

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Search List for the E-form / Codes Ostomy, Incontinence, Catheters Categories Product Eligible product Service codes Cecostomy Special Auth, CP Cecostomy Supplies A00101 Colostomy 1 piece system Disposable pouches - C A01011 Colostomy 1 piece system Drainable pouches - C A01011 Colostomy 2 piece system Wafer - C A01000 Colostomy 2 piece system Flanges - C A01000 Colostomy 2 piece system Disposable pouches - Co A01001 Colostomy 2 piece system Drainable pouches - Co A01001 Colostomy 2 piece system Mini-pouches - C A01001 Colostomy 2 piece system Seals - C A01002 Colostomy 2 piece system Barrier Rings - C A01002 Colostomy 2 piece system Convex insert - C A01002 Colostomy Accessory Ostomy belt - Custom C A01003 Colostomy Accessory Ostomy belt - C A01003 Colostomy Accessory Deodorizer (pouch only) - C A01003 Colostomy Accessory Skin Barrier - Liquid - C A01003 Colostomy Accessory Skin Barrier - Paste - C A01003 Colostomy Accessory Skin Barrier - Powder - C A01003 Colostomy Accessory Adhesive remover - C A01003 Colostomy Accessory Tape - C A01003 Colostomy Accessory Clamp - C A01003 Colostomy Accessory Tail closures - C A01003 Colostomy Accessory Stoma cover - C A01003 Colostomy Accessory Stoma Cap - C A01003 Colostomy Accessory Colomajic Liners - C A01003 Colostomy Irrigation Irrigation Kit - C A01004 Colostomy Irrigation Luer lock Cath Tip Syringes - C A01004 Colostomy Irrigation Irrigation Sleeve - C A01004 External Caths Accessory Quick drain valve - Ex C01001 External Caths Accessory Cath Secure - Ex C01001 External Caths Accessory Adhesive Strips - Ex C01001 External Caths Accessory Other (not gloves) - Ex C01001 External Caths Bag system Leg bag w/ strap - Ex C01001 External Caths Bag system Night drain containers C01001 External Caths Catheter External cath C01000 External Caths Lubricant External cath lubricant C01002 Ileostomy 1 piece system Eakin Seals - I A01002 Ileostomy 1 piece system Drainable pouches - I A01011 Ileostomy 2 piece system Wafer - I A01000 Ileostomy 2 piece system Flanges - I A01000 Ileostomy 2 piece system Drainable pouches - Il A01001

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Categories Product Eligible product Services Codes Ileostomy 2 piece system Seals - I A01002 Ileostomy 2 piece system Barrier Rings - I A01002 Ileostomy 2 piece system Convex insert - I A01002 Ileostomy Accessory Ostomy belt - Custom - I A01003 Ileostomy Accessory Ostomy belt - I A01003 Ileostomy Accessory Deodorizer (pouch only) I A01003 Ileostomy Accessory Skin Barrier - Liquid - I A01003 Ileostomy Accessory Skin Barrier - Paste - I A01003 Ileostomy Accessory Skin Barrier - Powder - I A01003 Ileostomy Accessory Adhesive Remover - I A01003 Ileostomy Accessory Tape - I A01003 Ileostomy Accessory Clamp - I A01003 Ileostomy Accessory Tail closures - I A01003 Ileostomy Accessory Cath tips - I A01003 Ileostomy Accessory Dressings - I A01003 Ileostomy Irrigation Irrigation Kits - I A01003 Ileostomy Lubricant Lubricant - I A01004 Incontinence Disposable Diapers - D E01000 Incontinence Disposable Incontinence briefs - D E01000 Incontinence Disposable Incontinence pads - D E01001 Incontinence Disposable Underpads - D E01001 Incontinence Disposable Chair pads - D E01001 Incontinence Disposable Bed Pads - D E01001 Incontinence Disposable Liners - D E01002 Incontinence Disposable Inserts - D E01002 Incontinence Miscellaneous Non-sterile gloves A00101 Incontinence Miscellaneous Non-medicated barrier cream A00101 Incontinence Miscellaneous Other (Not special auths) A00101 Incontinence Washable Diapers - W E01000 Incontinence Washable Incontinence briefs - W E01000 Incontinence Washable Incontinence pads - W E01001 Incontinence Washable Underpads - W E01001 Incontinence Washable Chair pads - W E01001 Incontinence Washable Bed Pads - W E01001 In-dwelling Caths Accessory Foley Cath Trays B01001 In-dwelling Caths Accessory Extension Tubing B01002 In-dwelling Caths Accessory Cath Secure - Ind B01002 In-dwelling Caths Accessory Adhesive Strips - Ind B01002 In-dwelling Caths Accessory Drain Valve B01002 In-dwelling Caths Accessory Other (not gloves) Ind B01002 In-dwelling Caths Bag system Leg bag w/ strap B01002 In-dwelling Caths Bag system Leg bag Kit B01002

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Categories Product Eligible product Service Codes In-dwelling Caths In-dwelling Cath Catheter B01000 In-dwelling Caths Irrigation Irrigation Trays B01003 In-dwelling Caths Irrigation Luer lock Cath Tip Syringes B01003 In-dwelling Caths Irrigation Saline or Sterile Water B01003 In-dwelling Caths Lubricant Lubricant - Ind B01004 Intermittent Caths Catheter Catheter - Int D01000 Intermittent Caths Lubricant Lubricant Tube - Int D01001 Intermittent Caths Lubricant Lubricant packs - Int D01001 Laxative Bisacodyl (Brand) 5 MG Suppository A00100 Laxative Bisacodyl (Brand) 10 MG Suppository A00100 Laxative Bisacodyl (Generic) 5 MG Suppository A00100 Laxative Bisacodyl (Generic) 10 MG Suppository A00100 Laxative Lactulose (Brand) 667 MG/ML ORAL LIQ A00100 Laxative Lactulose (Generic) 667 MG/ML ORAL LIQ A00100 Laxative PEG 3350 (Brand) 3350 Powder A00100 Laxative PEG 3350 (Generic) 3350 Powder A00100 Laxative Sennoside (Brand) 8.6 MG Tablets A00100 Laxative Sennoside (Generic) 8.6 MG Tablets A00100 Laxative Sodium Phosphate (Brand) KIT A00100 Laxative Sodium Phosphate (Generic) KIT A00100 Special Auth Shipping, OS Outside city limits, OS A00103 Special Auth Special Auth Cleansing Supplies A00101 Special Auth Special Auth Medicated Creams A00101 Special Auth Special Auth Transparent Dressings A00101 Special Auth Special Auth Hydrocolloid Dressings A00101 Special Auth Special Auth Waterproof products A00101 Special Auth Special Auth Hypoallergenic products A00101 Special Auth Special Auth Absorbent flakes A00101 Special Auth Special Auth Anal Catheters A00101 Special Auth Special Auth Anal Catheter supplies A00101 Urostomy 1 piece system Drainable pouches - U A01011 Urostomy 1 piece system Leg bag w/ Tubing - U A01011 Urostomy 1 piece system Night drain containers - U A01011 Urostomy 1 piece system Cath Secure - U A01011 Urostomy 1 piece system Adhesive Strips - U A01011 Urostomy 2 piece system Wafer - U A01000 Urostomy 2 piece system Flanges - U A01000 Urostomy 2 piece system Drainable pouches - Ur A01001 Urostomy 2 piece system Seals - U A01002 Urostomy 2 piece system Barrier Rings - U A01002 Urostomy 2 piece system Convex insert - U A01002 Urostomy Accessory Ostomy belt - Custom U A01003

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Categories Product Eligible product Service Codes Urostomy Accessory Ostomy belt - U A01003 Urostomy Accessory Deodorizer (pouch only) U A01003 Urostomy Accessory Skin Barrier - Liquid U A01003 Urostomy Accessory Skin Barrier - Paste U A01003 Urostomy Accessory Skin Barrier - Powder U A01003 Urostomy Accessory Adhesive remover U A01003 Urostomy Accessory Tape - U A01003 Urostomy Accessory Clamp - U A01003 Urostomy Accessory Tail closures - U A01003 Urostomy Continent diversion Cath tips - U A01003 Urostomy Continent diversion Dressings - U A01003 Urostomy Continent diversion Lubricant - U A01003

Therapeutic Nutrients, Dietary / Oral supplements Categories Product Eligible product Service Codes Dietary Supplement Oral Supplements Generic C00100 Dietary Supplement Oral Supplements Special Auth: Brand C00100 Dietary Supplement Oral Supplements Specialized C00100 Special Auth Shipping, TN Outside city limits, TN A00400 Therapeutic Nutrients Feeding Formula Formula B00100 Therapeutic Nutrients Feeding Pump Machine purchase B00102 Therapeutic Nutrients Feeding Pump Co-pay purchase B00102 Therapeutic Nutrients Feeding Pump Machine repair B00200 Therapeutic Nutrients Feeding Pump Machine rental B00301 Therapeutic Nutrients Feeding Supplies Backpack B00101 Therapeutic Nutrients Feeding Supplies Cath adapter B00101 Therapeutic Nutrients Feeding Supplies Decompression set B00101 Therapeutic Nutrients Feeding Supplies Extension Sets B00101 Therapeutic Nutrients Feeding Supplies Gastronomy button B00101 Therapeutic Nutrients Feeding Supplies Gastronomy Tube B00101 Therapeutic Nutrients Feeding Supplies Gravity Bags B00101 Therapeutic Nutrients Feeding Supplies Gravity Sets B00101 Therapeutic Nutrients Feeding Supplies IV pole B00101 Therapeutic Nutrients Feeding Supplies Pump bags B00101 Therapeutic Nutrients Feeding Supplies Pump sets B00101 Therapeutic Nutrients Feeding Supplies Skin balloon B00101 Therapeutic Nutrients Feeding Supplies Tube Feeding: Other B00101 Therapeutic Nutrients Feeding Supplies Tube Feeding: Supplies B00101

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Respiratory Services Categories Product Eligible product Service Codes Respiratory Services Breathing Aids Aerosol purchase A00100 Respiratory Services Breathing Aids Nebulizer purchase A00100 Respiratory Services Breathing Aids Aerosol mask A00101 Respiratory Services Breathing Aids Chest vibrator A00102 Respiratory Services Breathing Aids Lung Vol. Recruit. A00104 Respiratory Services Breathing Aids Humidifier A00105 Respiratory Services Breathing Aids Dehumidifier A00106 Respiratory Services Breathing Aids Aerosol Supplies A00111 Respiratory Services Breathing Aids Nebulizer supplies A00114 Respiratory Services Breathing Aids Aerosol repairs A00200 Respiratory Services Breathing Aids Suction repairs A00200 Respiratory Services Breathing Aids Suction Machine A01200 Respiratory Services Breathing Aids Suction supplies A01211 Respiratory Services Spacing Device Adult Aerochamber A01100 Respiratory Services Spacing Device Adult Optichamber A01100 Respiratory Services Spacing Device Mask (Aero/Opti) Adult A01100 Respiratory Services Spacing Device Child Aerochamber A01101 Respiratory Services Spacing Device Child Optichamber A01101 Respiratory Services Spacing Device Mask (Aero/Opti) Child A01101 Respiratory Services Tracheostomy Trach supplies A00112

Medical Supplies Categories Product Eligible product Service Codes Medical Services Blood Pressure Monitor A00104 Medical Services Burn garments Supplies, BG A00102 Medical Services Compression 1st pr comp. stocking D01000 Medical Services Compression 1st pr comp. sleeve D01001 Medical Services Compression 2nd pr. comp. stocking D01010 Medical Services Compression 2nd pr. comp. sleeve D01011 Medical Services Convalescent 2 wheel walker A01001 Medical Services Convalescent Cane A00101 Medical Services Convalescent Crutches A00101