Chapter 14: Traumatic Brain Injury and Traumatic Spinal Cord Injury – Ancillary Goods and Services

14.1 Overview

Goods and services related to a person’s traumatic brain injury (TBI) or traumatic spinal cord injury (TSCI), which are not outpatient therapy services and are not delivered as part of inpatient comprehensive medical rehabilitation services or post-acute rehabilitation services, are considered ancillary. Ancillary services are preauthorized by CRS counselors according to CRS policy, and are reimbursed according to the reimbursement methodology described in 1 TAC §355.9040. These services may include durable medical equipment, orthotics, prosthetics, assistive technology devices, medications, medical equipment and supplies, home modifications, transportation that is required to enable participation in a CRS approved service, and paraprofessional services that are required to enable participation in therapy sessions to assist with meeting treatment goals and independence in the home and community.

14.2 Durable Medical Equipment

Durable Medical Equipment (DME) is any equipment that provides therapeutic benefits to a person with a medical condition and should be purchased utilizing contracted providers and must be pre-authorized by the CRS counselor. If no contracted provider is available, a vendor may be utilized if appropriate approvals are obtained.

14.3 Home Modifications

Home modifications are changes made to the participant’s physical environment to increase their accessibility to perform activities of daily living to function independently in the home and community. Any home modifications that the CRS program approves needs to have an assessment and gather professional recommendations prior to approval and purchase.

The home modification process begins with a full assessment of needs, followed by consideration of accommodation alternatives. This includes the need for participant training and education on the use of rehabilitation technology. The participant needs to make an informed choice about how to best meet their needs, considering the advantages of low-tech equipment over high-tech equipment, the need to maintain equipment, the possibility of maintenance costs, and the timeliness with which the equipment can be purchased. Creating an accessible environment for independent living may include, but is not limited to ramps and adaptive equipment such as stair glides and lifts.

Adaptive equipment may require installation, but usually does not result in permanent structural changes. Household equipment may be specially designed, selected, or altered to enable the participant to perform homemaker duties despite their functional limitations.
Modifications are limited to equipment that can be removed from the residence without permanent damage to the property should the participant move or fail to cooperate in achieving the planned objective.

Obtain a written agreement using the Form 3107, CRS Resident Site Modification Waiver and Agreement, signed by the participant, the property owner or both for any equipment such as a porch, ramp, or bathroom grab bars is attached (for example, bolted or nailed) to the property.  This document needs to be filled in completely and clearly justify the reason that the modification supports the participant's planned rehabilitation outcome. If the lien holder or property owner will not sign the disclaimer or there are circumstances of minor edits to the agreement, contact Legal Services for guidance. Provide a copy of Form 3107, CRS Resident Site Modification Waiver and Agreement, to the participant, lien holder or property owner, and keep the original in the participant’s case file.

14.4 Required Documentation

The provider must submit an Individualized Program Plan that identifies the ancillary goods and services needed for the participant to obtain authorization from the CRS program staff member. For durable medical equipment an evaluation or a prescription is required to verify medical necessity. A quote with the MSRP must be submitted to the CRS program staff for pre-authorizations. The provider summarizes in detail the ancillary goods and services provided, justifies the need (for example, by including assessments and quotes for costs), and submits supporting documentation (such as receipts for prescriptions). See Chapter 6 General Billing Guidelines for additional information.

14.5 Billing Guidelines

The provider must submit quotes or a request for pre-authorization of services. The provider must submit a detailed summary of the ancillary goods or services provided, along with the invoice. For verification of contracted DME discounts, the provider must submit a copy of the manufacturer’s suggested retail price (MSRP) with the invoice. Warranties and repairs must be included in the quotes if applicable. If a participant has a third-party insurance or comparable benefit, the contracted DME provider must also submit a copy of the explanation of benefits or denial before payment can be authorized. If the provider provides services outside of the proposed or confirmed dates, payment is not guaranteed. The provider is responsible for billing, collecting, or writing-off costs owed by the liable party. The CRS program is the payer of last resort.

14.6 Exceptions and Limitations

If a participant requires medical treatment for an injury sustained while receiving rehabilitation services or requires treatment for an illness that is not related to the participant’s TBI or TSCI, the participant is considered medically unstable and the services are not covered by the CRS program.

If products or services are not under contract or a Maximum Affordable Payment Schedule purchase and the cost is less than $5,000.00, the purchase should be completed using a commercial source. Purchases of goods and services in the amount of $5,000 or less from a single vendor are not required to have competitive bids, but must conform to the purchasing guidelines. All purchases, except contracted services, costing more than $5,000, must be competitively bid or approved as a Proprietary or Sole Source Purchase. The following approvals are required for ancillary goods and services:

Purchase costs per item Approval needed from Competitive bids required
$2,000 or less Counselor No
$2,000 to $5,000 Supervisor No
$5,000 -$25,000 Supervisor

Required for goods or services greater than $5,000 if the purchase is:

  • Not a contracted item
  • Not using the Maximum Affordable Payment Schedule fee schedule
$25,000 and more Manager

Required for goods or services greater than $5,000 if the purchase is:

  • Not a contracted item
  • Not using the Maximum Affordable Payment Schedule fee schedule