Payment is subject to Prior Authorization requirements and is based either on Medicare’s definitions of DMEPOS categories or the MHP DMEPOS Fee Schedule.
Items with a purchase price of $1,000 or more or a rental price of $100 or more. Purchased items are HCPCS codes either without a modifier or have a 'NU' modifier;
Customized DMEPOS;
Oxygen;
Back-up Equipment;
A few items, those classified by CMS as 'FS' or 'Items Requiring Frequent and Substantial Servicing,' rent as long as there is Medical Necessity for the item. These items remain owned by the providing DME company. Continuous rental is paid and Maintenance is not allowed;
Other rented items are reimbursed until the purchase price is met. All payments for rental are applied towards the purchase price should an item be converted to purchase prior to the purchase price being met by sequential rental payments; and
Some rental items may begin as rental for a specified period prior to purchase or continued rental pending proof of patient compliance or an improvement in health status. Examples include CPAPs and TENS units.
Most DMEPOS are purchased. Those HCPCS codes either have no modifier or a 'NU' modifier.
Items that are deemed 'purchase only' that are billed with a 'RR' modifier, indicating 'Rental' should be denied and re-billed for purchase of the item.
Oxygen equipment rents for 36 months and then rental payments cease. The equipment ownership is maintained by the DME company and payments for maintenance are authorized.
When a stationary oxygen system is being rented, the monthly allowance includes payment for all required contents.
If the member uses an oxygen stationary system that has reached rental cap, other than an oxygen concentrator or uses a portable system only, payment may be made for contents.
If the member uses a stationary system and a portable system, the portable content fee is never payable in addition to the regular content fee.
Additional or reduced payments for contents are payable based on the 'QF' modifier for 150% of the payable amount and the 'QE' modifier for 50% of the payable amount.
DME delivery, set up and/or dispensing services (e.g., A9901) will not be reimbursed separately to the provider and shall be included as part of the DME charge. If the fees are submitted separately to MHP, they will be denied and may not be balanced billed to the Member.
Routine periodic servicing, such as testing, cleaning, regulating, and checking of the member’s equipment, is not covered. However, more extensive maintenance which, based on the manufacturers’ recommendations, is to be performed by authorized technicians, is covered as repairs for medically necessary equipment which a member owns.