Durable Medical Equipment FAQs
Durable Medical Equipment FAQs
What is Durable Medical Equipment?
The Centers for Medicare and Medicaid Services defines durable medical equipment as equipment that meets these conditions:
- Can withstand repeated use.
- Is used for a medical reason.
- Not usually useful to someone who is not sick or injured.
- For use in the home environment.
- Has an expected lifetime of at least five years.
How is DME Covered By My Health Plan?
Medicare and Medicaid both offer DME coverage. Private health insurance plans are not required to cover DME, but many do. In general, each health plan requires the following information:
- A signed and dated prescription from a doctor of medicine, doctor of osteopathy (must be licensed to practice and medicine and surgery), physician assistant, nurse practitioner, or clinical nurse specialist.
- Medical record documentation demonstrating evidence of medical necessity for the prescribed equipment.
- Medical provider documentation validating use of the equipment in the home.
- For select equipment and supplies, some medical health plans require prior authorization before delivery.
- A clinical evaluation: an in person or insurance provider approved telehealth visit with the health care professional and the patient.
- Additional laboratory results to validate medical need for some respiratory equipment such as oxygen, continuous positive airway pressure therapy, bi-level pressure therapy, non-invasive ventilation, and enteral feeding.
Once the medical necessity has been established for the prescribed medical equipment, the medical plan will reimburse Prism Health Care Services on a rent-to-own or one-time purchase for the member. Prism Health Care Services will submit the claim for rent to own or purchase in accordance with the medical health plan rules.
Medicare-covered patients can expect the equipment to be converted to purchase after 13 months of consecutive use.*
Medicaid patients can expect the equipment to be converted to purchase after 10 months of consecutive use.*
Private health plans’ convert-to-purchase options vary by plan.*
*Due to frequent service and maintenance needs for oxygen and non-invasive ventilation equipment, your medical health plan will not purchase these devices; they will remain rental items.
What Should a DME Prescription Include?
A valid prescription must include:
- Patient’s name or Medicare beneficiary identifier.
- Order date.
- General description of the item.
- For equipment: Description should include base item and accessories or additional features that are separately billed listed separately.
- For supplies: In addition to the base item, include all ordered supplies listed separately.
- Quantity to be dispensed, when applicable.
- Name of prescribing doctor of medicine, osteopathy, physician assistant, nurse practitioner, or clinical nurse specialist or national provider identification number (NPI).
- Signature of prescribing doctor of medicine, osteopathy, physician assistant, nurse practitioner, or clinical nurse specialist with national provider identification number (NPI).
Please note that prescriptions for supplies must list all supplies separately.
What is the Required Face-to-Face Encounter for DME Prescriptions?
As a condition for payment, all medical health plans require a face-to-face encounter with the prescribing health care professional and the patient. The in-person meeting must support payment for the prescribed item(s) and be documented in the medical record. The supporting documentation must include subjective and objective patient specific information for diagnosing, treating, or managing the clinical condition for the DME that is being ordered. The face-to-face does not have to mention the prescribed medical equipment; however, it must justify the medical need.
Justification for the medical equipment upon completion of the face-to-face encounter can be achieved through documentation from other health care providers such as a nurse, physical therapist, specialty doctor (e.g., pulmonology, sleep medicine, neurology, etc.) or home health nurse.
The face-to-face encounter also includes examinations via the approved use of telehealth examinations meeting the requirements of items 42 CFR §§410.78 and 414.65 in the CMS manual. Some medical equipment policies may still require an in-person evaluation.
How Much Does DME Cost?
For in-network medical health plans, Prism Health Care Services will submit claims in accordance with the contractual allowed amount for the equipment. Prism Health Care Services completes an insurance verification for every patient order. The insurance verification will provide information about:
- Durable medical equipment coverage.
- Additional medical documentation required by the health plan.
- Patient financial responsibility.
- In-network provider status.
Medicare: After meeting the Medicare Part B deductible, the patient is responsible for 20% of the Medicare-approved amount for items in which Prism Health Care Services accepts assignment. For customers who have a secondary health insurance plan, the 20% co-payment may be paid by the health plan.
Medicaid: Medicaid- and Medicaid-managed care plans cover medical equipment at 100% when the medical criteria have been established and the health plan has provided prior approval.
Private health plans: After the patient meets the annual deductible and co-insurance amounts, the DME is covered based on the individual plan.
How Does Prism Coordinate Care and Delivery of Services in the Home?
Prism Health Care Services will coordinate delivery of durable medical equipment upon receiving the health medical plan required documentation for delivery of services. Once the order has been approved in accordance with the medical plan requirements, our team will contact the patient/caregiver for the following.
- Review financial responsibility.
- Collect any out-of-pocket costs not covered by the medical health plan.
- Coordinate and schedule delivery of the prescribed equipment.
- Contingent on the prescribed equipment the delivery personnel will provide the following.
- Equipment education
- Related accessories for safe operation
- Information on how to disinfect or care for the prescribed equipment
- A review of emergency preparedness
- A home safety inspection (when applicable) to identify any safety or health hazards. Home safety hazards may include:
- Throw rugs
- Furniture layout
- Bathroom safety
- Cluttered stairways or blocked exits
- Presence of smoke detector (for fire safety when oxygen is in use)
- Fire risks
- Unsecured doors
- The required proof-of-delivery paperwork to submit to the medical health plan
- Equipment return demonstration.
- How to contact Prism Health Care Services in case of an emergency. Prism Health Care Services provides 24/7 on-call services for life-sustaining equipment such as bi-level respiratory assist devices, non-invasive ventilation, oxygen and enteral food pumps.
- Submit the bill to the medical health plan for reimbursement.
- Obtain ongoing prior approval and other required documents for the length of the equipment rental period.
Important notice: Prism Health Care Services delivery personnel are prohibited from moving or relocating personal furniture for patients. For customers receiving medical equipment such as hospital beds and patient lifts, please make sure to have the area clear for the delivery personnel. In addition, Prism Health Care Services is not responsible for moving medical equipment from one address to another. Customers or caregivers must make their own independent arrangements for address changes and notify Prism of the new location.