AI-assisted research summary: Custom orthotic and custom prosthetic devices furnished to an individual must meet listed provider, accreditation, and prescription requirements, and certain providers may not bill patients for denied coverage amounts.
36-2411 - Custom orthotic and custom prosthetic devices; requirements; definition 36-2411. Custom orthotic and custom prosthetic devices; requirements; definition A. Beginning January 1, 2018, a custom orthotic or custom prosthetic device furnished to an individual shall meet all of the following requirements: 1. Except for a custom orthotic or custom prosthetic device provided by a health care provider who is licensed pursuant to title 32, chapter 7, 13, 17, 19, 25 or 34, be provided by a fabricator or supplier that is accredited by an independent accreditation organization approved by the secretary of the United States department of health and human services pursuant to 42 United States Code section 1395m(a)(20)(B) and the regulations promulgated thereunder. 2. Be provided by a health care provider that is a qualified practitioner as defined in 42 United States Code section 1395m(h)(1)(F) or is licensed pursuant to title 32, chapter 7, 13, 17, 19, 25 or 34. 3. Be the subject of a valid prescription for the custom orthotic or custom prosthetic device. B. Except for a custom orthotic or custom prosthetic device provided by a health care provider who is licensed pursuant to title 32, chapter 7, 13, 17, 19, 25 or 34, a health care provider that does not receive insurance payment for a custom orthotic or custom prosthetic device because the custom orthotic or custom prosthetic device or the provider does not meet the requirements of subsection A of this section may not attempt to collect payment or reimbursement for the amount of the coverage denial for the custom orthotic or custom prosthetic device from the patient. This subsection applies only if the coverage denial is strictly based on the custom orthotic or custom prosthetic device or the provider not meeting the requirements of subsection A of this section. C. This section does not: 1. Require a health care provider to accept medicare patients. 2. Restrict the ability of a licensed health care provider to issue a valid prescription for a custom orthotic or custom prosthetic device pursuant to the applicable state law provided that the custom orthotic or custom prosthetic device is molded, fabricated and fitted by a provider pursuant to subsection A of this section. 3. Prevent a licensed health care provider, that does not meet the requirements in subsection A of this section, from engaging in the profession or occupation for which the health care provider is licensed, provided that the licensed health care provider does not bill or otherwise receive insurance payment or collect reimbursement from a patient for the custom orthotic or custom prosthetic device. D. For the purposes of this section, "custom orthotic or custom prosthetic device" means an orthotic or prosthetic device that is individually fabricated for a patient over a positive mold, a tracing or a scan of the patient. Custom orthotic or custom prosthetic device does not include shoes and shoe inserts, a dental device, a hearing-related device or the replacement of all or part of an internal body organ.