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Both Medicare and private health insurance
plans pay for a large portion or sometimes even all
costs associated with many types of medical equipment
used in the home. This type of equipment is referred to
as durable medical equipment (DME) or home medical
equipment. The information below will help you
understand the guidelines Medicare provides related to
home medical equipment. Most health insurance plans have
similar rules to Medicare, but you should know that all
private health insurance plans vary and the specific
rules of your plan may differ from these Medicare
guidelines. We accept most of the major health insurance
plans. We would be happy to work with you and your
insurance company to help you understand how your plan
works as it relates to home medical equipment needed by
you or a loved one.
Reference directory:
I. Guide to Medicare Coverage
II. Medicare Coverage for
specific type of home medical equipment
III. Medicare Supplier
Standards
I. Guide to
Medicare Coverage
Who qualifies for Medicare benefits?
-
Individuals 65 years of age or older
-
Individuals under 65 with permanent kidney failure
(beginning three months after dialysis begins), or
-
Individuals under 65, permanently disabled and
entitled to Social Security benefits (beginning 24
months after the start of disability benefits)
The Different Benefits of Traditional
Medicare
-
Medicare Part A benefits cover hospital stays, home
health care and hospice services.
-
Medicare Part B benefits cover physician visits,
laboratory tests, ambulance services and home
medical equipment.
-
While oftentimes you do not have to pay a monthly
fee to have Part A benefits, the Part B program
requires a monthly premium to stay enrolled. In 2010
that premium will range between $96.40 and $353.60
per month depending on your income. Typically, this
amount will be taken from your Social Security
check.
What Can You Expect to Pay?
-
Every year, in addition to your monthly premium, you
will have to pay the first $135 of covered expenses
out of pocket and then 20 percent of all approved
charges if the provider agrees to accept Medicare
payments.
-
Unfortunately, your medical equipment provider
cannot automatically waive this 20 percent or your
deductible without suffering penalties from
Medicare. Your provider must attempt to collect the
coinsurance and deductible if those charges are not
covered by another insurance plan; however, certain
exceptions can be made if you suffer from qualifying
financial hardships.
-
If you have a supplemental insurance policy, that
plan may pick up this portion of your responsibility
after your supplemental plan’s deductible has been
satisfied.
-
If your medical equipment provider does not accept
assignment with Medicare you may be asked to pay the
full price up front, but they will file a claim on
your behalf to Medicare. In turn, Medicare will
process the claim and mail you a check to cover a
portion of your expenses if the charges are
approved.
Other possible costs:
-
Medicare will pay only for items that meet your
basic needs.
Oftentimes you will find that your provider offers a
wide selection of products that vary slightly in
appearance or features. You may decide that you
prefer the products that offer these additional
features. Your provider should give you the option
to allow you to privately pay a little extra money
to get the product that you really want.
-
To take advantage of this opportunity, a new form
has been approved by the Centers for Medicare and
Medicaid Services (CMS) that allows patients to
upgrade to a piece of equipment that they like
better than other standard options for which they
may otherwise qualify.
-
The Advance Beneficiary Notice, or ABN, must detail
how the products differ, and requires a signature to
indicate that you agree to pay the difference in the
retail costs between two similar items. Your
provider will typically accept assignment on the
standard product and apply that cost toward the
purchase of the fancier item, thus requiring less
money out of your pocket.
Purpose of ABN
-
The Advance Beneficiary Notice also will be used to
notify you ahead of time that Medicare will probably
not pay for a certain item or service in a specific
situation, even if Medicare might pay under
different circumstances. The form should be detailed
enough that you understand why Medicare will
probably not pay for the item you are requesting.
-
The purpose of the form is to allow you to make an
informed decision about whether or not to receive
the item or service knowing that you may have
additional out-of-pocket expenses.
Durable Medical Equipment (DME) Defined
-
In order for any item to be covered under Medicare,
it typically has to meet the test of durability.
Medicare will pay for medical equipment when the
item:
-
Withstands repeated use (excludes many
disposable items such as underpads)
-
Is used for a medical purpose (meaning there is
an underlying condition which the item should
improve)
-
Is useless in the absence of illness or injury
(thus excluding any item preventive in nature
such as bathroom safety items used to prevent
injuries)
-
Used in the home (which excludes all items that
are needed only when leaving the confines of the
home setting)
Understanding Assignment (a claim-by-claim
contract)
-
When providers accept assignment, they are agreeing
to accept Medicare’s approved amount as payment in
full.
-
You will be responsible for 20 percent of that
approved amount. This is called your coinsurance.
-
You also will be responsible for the annual
deductible, which is $135.00.
-
If a provider does not accept assignment with
Medicare, you will be responsible for paying the
full amount upfront. The provider will still file a
claim on your behalf and any reimbursement made by
Medicare will be paid to you directly. (Providers
must still notify you in advance, using the Advance
Beneficiary Notice, if they do not believe Medicare
will pay for your claim.)
Mandatory Submission of Claims
-
Every provider is required to submit a claim for
covered services within one year from the date of
service
The role of the physician with respect to
home medical equipment:
-
Every item billed to Medicare requires a physician’s
order or a special form called a Certificate of
Medical Necessity (CMN), and sometimes additional
documentation will be required.
-
Nurse Practitioners, Physician Assistants, Interns,
Residents and Clinical Nurse Specialists can also
order medical equipment and sign CMNs when they are
treating a patient.
-
All physicians have the right to refuse to complete
documentation for equipment they did not order, so
make sure you consult with your physician before
requesting an item from a provider.
Prescriptions Before Delivery:
-
For some items, Medicare requires your provider to
have completed documentation (which is more than
just a call-in order or a prescription from your
doctor) before these items can be delivered to you:
-
Decubitus care (wheelchair cushions and
pressure-relieving surfaces placed on a hospital
bed)
-
Seat lift mechanisms
-
TENS Units (for pain management)
-
Power Operated Vehicles/Scooters
-
Electric or Power Wheelchairs
-
Negative Pressure Wound Therapy (wound vacs)
How does Medicare pay for and allow you to
use the equipment?
-
Typically there are four ways Medicare will pay for
a covered item:
-
Purchase it outright; then the equipment belongs
to you,
-
Rent it continuously until it is no longer
needed, or
-
Consider it a “capped” rental in which Medicare
will rent the item for a total of 13 months and
consider the item purchased after having made 13
payments.
-
Medicare will not allow you to purchase these items
outright (even if you think you will need it for a
long period of time).
-
This is to allow you to spread out your coinsurance
instead of paying in one lump sum.
-
It also protects the Medicare program from paying
too much should your needs change earlier than
expected.
-
If you have oxygen therapy, Medicare will make
rental payments for a total of 36 months during
which time this fee covers all service, accessories,
and oxygen contents.
-
Beyond the 36 months, Medicare will limit payments
to replacement of accessories, and allows a small
fee for monthly content and to check the equipment
every six months.
-
After an item has been purchased for you, you will
be responsible for calling your provider any time
that item needs to be serviced or repaired. When
necessary, Medicare will pay for a portion of
repairs, labor, replacement parts, and for temporary
loaner equipment to use during the time your product
is in for servicing. All of this is contingent on
the fact that you still need the item at the time of
repair and continue to meet Medicare’s coverage
criteria for the item being repaired.
<<Back to Top>>
II. Medicare Coverage for Specific Types of Home Medical
Equipment
BiPaps/Respiratory Assist Devices
-
For a respiratory assist device to be covered, the
treating physician must fully document in your
medical record symptoms characteristic of
sleep-associated hypoventilation, such as daytime
hypersomnolence, excessive fatigue, morning
headaches, cognitive dysfunction, dyspnea, etc.
-
A respiratory assist device is covered for those
patients with clinical disorder groups characterized
as (I) restrictive thoracic disorders (i.e.,
progressive neuromuscular diseases or severe
thoracic cage abnormalities), (II) severe chronic
obstructive pulmonary disease (COPD), (III) central
sleep apnea (CSA), or (IV) obstructive sleep apnea (OSA).
-
Various tests may need to be performed to establish
one of the above diagnosis groups.
-
Three months after your therapy is begun, both your
physician and you will be required to respond in
writing to questions regarding your continued use
along with how well the machine is treating your
condition.
Breast Prostheses Breast Prostheses are covered after a radical
mastectomy. Medicare will cover:
-
One silicone prosthesis every two years or a
mastectomy form every six months.
-
Mastectomy bras are covered as needed.
There is no coverage for
replacement prostheses due to wear and tear before the
specified time frames. However, Medicare will cover
replacement of these items due to:
-
Loss
-
Irreparable damage, or
-
Change in medical condition (e.g. significant weight
gain/loss)
Patients are allowed only one
prosthesis per affected side; others will be denied as
not medically necessary even if attempting symmetry (an
ABN should be provided in this circumstance)
Mastectomy sleeves which are used to control
swelling are not covered in the home setting because
they do not meet Medicare’s definition of a prosthesis;
however, it is possible that they may be covered under
the hospital per diem if you request one during your
hospital stay.
Cervical Traction
-
Cervical traction devices are covered only if both
of the criteria below are met:
-
The patient has a musculoskeletal or neurologic
impairment requiring traction equipment.
-
The appropriate use of a home cervical traction
device has been demonstrated to the patient and
the patient tolerated the selected device.
Commodes
-
Heavy-duty commodes are covered for patients
weighing over 300 pounds.
-
A commode is only covered when the patient is
physically incapable of utilizing regular toilet
facilities.
For example:
-
The patient is confined to a single room, or
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The patient is confined to one level of the home
environment and there is no toilet on that level, or
-
The patient is confined to the home and there are no
toilet facilities in the home.
Compression Stockings
-
Gradient compression stockings worn below the knee
are covered only when used for the treatment of open
venous stasis ulcers. They are not covered for the
prevention of ulcers, prevention of the reoccurrence
of ulcers or treatment of lymphedema without ulcers.
CPAPs
-
Continuous Positive Airway Pressure (CPAP) Devices
are covered only for patients with obstructive sleep
apnea (OSA).
-
Patients must have an overnight sleep study
performed in a sleep laboratory to establish a
qualifying diagnosis. In March of 2008, home sleep
testing was approved as an acceptable means of
diagnosing this condition when your physician deems
this testing is appropriate.
-
Medicare will also pay for replacement masks,
cannulas, tubing and other necessary supplies.
-
After the first three months of use, you will be
required to verify if you are benefiting from using
the device and how many hours a day you are using
the machine.
Diabetic Supplies
-
For diabetics, Medicare covers the glucose monitor,
lancets, spring-powered lancing devices, test
strips, control solution, and replacement batteries
for the meter.
-
Medicare does not cover insulin injections or
diabetic pills unless covered through a Medicare
Part D benefit plan.
-
Diabetics can obtain up to a three-month supply at a
time.
-
Medicare will approve up to one test per day for
non-insulin-dependent diabetics and three tests per
day for insulin-dependent diabetics without
additional verification.
-
Patients who test above these guidelines are
required to be seen and evaluated by their physician
within six months of ordering these supplies.
-
In addition, patients must send their provider
evidence of compliant testing (e.g. a testing log)
every six months to continue getting refills at the
higher levels.
-
If at any time your testing frequency changes, your
physician will need to give your provider a new
prescription.
Glasses
-
Medicare covers one complete pair of glasses after
the last cataract surgery. These can include:
-
frames
-
two lenses
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tint, anti-reflective coating, and/or UV (when the
doctor specifically orders these services for a
medical need)
Hospital Beds
-
Specialty beds that allow the height of the bed to
vary are covered for patients that require this
feature to permit transfers to a chair, wheelchair,
or standing position.
-
A semi-electric bed is covered for a patient who
requires frequent changes in body position and/or
has an immediate need for a change in body position.
-
Heavy-duty/extra-wide beds can be covered for
patients who weigh over 350 pounds.
-
The total electric bed is not covered because it is
considered a convenience feature. If the patient
prefers to have the total electric feature, the
provider usually can apply the cost of the
semi-electric bed toward the monthly rental price of
the total electric model by using an Advance
Beneficiary Notice (ABN). The patient would be
responsible to pay the difference in the retail
charges between the two items every month.
A hospital bed is covered if one or more
of the following criteria (1-4) are met:
-
The patient has a medical condition which requires
positioning of the body in ways not feasible with an
ordinary bed. Elevation of the head/upper body less
than 30 degrees does not usually require the use of
a hospital bed, or
-
The patient requires positioning of the body in ways
not feasible with an ordinary bed in order to
alleviate pain, or
-
The patient requires the head of the bed to be
elevated more than 30 degrees most of the time due
to congestive heart failure, chronic pulmonary
disease, or problems with aspiration. Pillows or
wedges must have been considered and ruled out, or
-
The patient requires traction equipment which can
only be attached to a hospital bed.
Lymphedema Pumps
-
Lymphedema Pumps are covered for treatment of true
lymphedema as a result of a:
-
Primary Lymphedema resulting from a congenital
abnormality of lymphatic drainage or Milroy’s
disease, or
-
Secondary lymphedema resulting from the
destruction of or damage to formerly functioning
lymphatic channels such as:
-
radical surgical procedures with removal of
regional groups of lymph nodes (for example,
after radical mastectomy),
-
post-radiation fibrosis,
-
spread of malignant tumors to regional lymph
nodes with lymphatic obstruction,
-
or other causes
-
Before you can be prescribed a pump, your
physician must monitor you during a four-week
trial period where other treatment options are
tried such as medication, limb elevation and
compression garments. If, at the end of the
trial, there is little or no improvement, a
lymphedema pump can be considered.
-
The doctor must then document an initial
treatment with a pump and establish that the
treatment can be tolerated.
-
Lymphedema pumps also are covered for the
treatment of chronic venus insufficiency (CVI).
-
Before you can be prescribed a pump for this
condition, your physician must monitor you
during a six month trial period where other
treatment options are tried such as medication,
limb elevation and compression garments. If at
the end of the trial the stasis ulcers are still
present, a lymphedema pump can be considered.
-
The doctor must then document an initial
treatment with a pump and establish that the
treatment can be tolerated, that there is a
caregiver available to assist with the treatment
in the home, and then the doctor must prescribe
the pressures, frequency, and duration of
prescribed use.
Medicare-covered drugs (other than
Medicare Part D coverage)
-
As of February, 2001, all providers of
Medicare-covered drugs are required to accept
assignment on these items.
-
Traditional Medicare Part B insurance will cover
some nebulizer drugs, some infused drugs using a
pump, specific immunosuppressive drugs, select oral
anti-cancer medications and most parenteral
nutrition.
-
The Medicare Part D plans may provide additional
coverage of other oral medications, inhalers and
similar drugs.
Mobility Products: Canes, Walkers, Wheelchairs, and
Scooters
Essentially the new Mobility Assistive
Equipment regulations will ensure that Medicare funds
are used to pay for:
-
Mobility needs for daily activities within the home
-
Least costly alternative/lowest level of equipment
to accomplish these tasks.
-
Most medically appropriate equipment (to meet the
needs, not the wants)
Medicare requires that your
physician and provider evaluate your needs and expected
use of the mobility product you will qualify for.
They must determine which is the least level of
equipment needed to help you be mobile within your home
to accomplish daily activities by asking the following
questions:
-
Will a cane or crutches allow you to perform these
activities in the home?
-
If not, will a walker allow you to accomplish these
activities in the home?
-
If not, is there any type of manual wheelchair that
will allow you to accomplish these activities in the
home?
-
If not, will a scooter allow you to accomplish these
activities in the home?
-
If not, will a power chair allow you to accomplish
these activities in the home?
Keep in mind if you have another higher level
product in mind that will allow you to do more beyond
the confines of the home setting, you can discuss with
your provider the option to upgrade to a higher level or
more comfortable product by paying an additional out of
pocket fee using the Advance Beneficiary Notice (ABN) to
select the product you like best.
-
A face-to-face examination with your physician is
required prior to the initial setup of a power chair
or scooter.
-
our home must be evaluated to ensure it will
accommodate the use of any mobility product.
Nebulizers
-
Nebulizer machines, medications, and related
accessories are usually covered for patients with
obstructive pulmonary disease, but can also be
covered to deliver specific medications to patients
with HIV, CF, brochiectasis, pneumocystosis,
complications of organ transplants, or for
persistent thick or tenacious pulmonary secretions.
-
Patients can obtain up to a three month’s supply of
nebulizer medications and accessories at a time.
Non-covered items (partial listing):
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Adult Diapers
-
Bathroom Safety
-
Hearing Aids
-
Syringes/Needles
-
Van Lifts or Ramps
-
Exercise Equipment
-
Humidifiers/Air Purifiers
-
Raised Toilet Seats
-
Massage devices
-
Stair Lifts
-
Emergcy Devices
-
Low Vision aids
-
Grab Bars
Orthopedic Shoes
-
Orthopedic shoes are covered when it is necessary to
attach the shoe(s) to a leg brace.
-
However, Medicare will only pay for the shoe(s)
attached to the leg braces.
-
Medicare will not pay for matching shoes or for
shoes that are needed for purposes other than for
diabetes or leg braces.
Ostomy Supplies Ostomy supplies are covered for people with a:
-
colostomy
-
ileostomy
-
urostomy
Patients can obtain up to a
three month’s supply of wafers, pouches, paste, and
other necessary items at a time.
Oxygen
Covered for patients with significant hypoxemia in the
chronic stable state when:
-
patient has a chronic lung condition or disease or
hypoxemia that might be expected to improve with
oxygen therapy, and
-
patient’s blood gas levels or oxygen saturation
levels indicate the need for oxygen therapy, and
-
alternative treatments have been tried or deemed
clinically ineffective.
Categories/Groups are based on the test results
to measure your oxygen:
-
I 55≤ mmHg, or 88%≤ saturation
For these results you must
return to your physician 12 months after the initial
visit to continue therapy for lifetime or until the need
is expected to end. Typically, you will not have to be
retested when you return to your physician for the
follow-up visit.
-
II 56-59 mmHg, or 89% saturation
-
For these results, you must be retested within 3
months of the first test to continue therapy for
lifetime or until the need is expected to end.
-
III ≥60 or ≥90% not medically necessary.
Oxygen will be paid as a rental for the first
36 months. After that time if you still need the
equipment Medicare will no longer make rental payments
on the equipment. If your deductible and copays are met,
the equipment title will transfer to you. Medicare will
then pay for refilling your oxygen cylinders and for
repairs and service of your equipment. Medicare will
also separately pay for oxygen accessories such as
tubing, masks, and cannulas after the purchase price has
been met.
Parenteral and enteral therapy
-
Parenteral therapy requires all or part of the
gastrointestinal tract be missing. Nutritional
formulas are delivered through a vein.
-
Enteral therapy is covered for patients who cannot
swallow or take food orally. Nutrition must be
delivered through a tube directly into the
gastrointestinal tract.
-
Medicare will not pay for nutritional formulas that
are taken orally.
Patient Lifts
-
A lift is covered if transfer between bed and a
chair, wheelchair, or commode requires the
assistance of more than one person and, without the
use of a lift, the patient would be bed confined.
-
An electric lift mechanism is not covered because it
is considered a convenience feature. If you prefer
to have the electric mechanism, your provider can
usually apply the cost of the manual lift toward the
purchase price of the electric model by using an
Advance Beneficiary Notice (ABN). You would be
responsible to pay the difference in the retail
charges between the two items.
Seat Lift Mechanisms
-
In order for Medicare to pay for a seat lift
mechanism, patients must be suffering from severe
arthritis of the hip or knee, or have a severe
neuromuscular disease. In addition they must be
completely incapable of standing up from any chair,
but once standing they can walk either independently
or with the aid of a walker or cane. The physician
must believe that the mechanism will improve, slow
down, or stop the deterioration of the patient’s
condition.
-
Transferring directly into a wheelchair will prevent
Medicare from paying for the device.
-
Medicare will only pay for the lift mechanism
portion. The chair portion of the package is not
covered, and you will be responsible for paying the
full amount for the furniture component of the
chair.
Support Surfaces
-
Group 1 products are designed to be placed on top of
a standard hospital or home mattress. They can
utilize gel, foam, water, or air, and are covered
for patients who are:
-
Completely immobile OR
-
Have limited mobility with any stage ulcer on
the trunk or pelvis (and one of the following):
-
impaired nutritional status
-
fecal or urinary incontinence
-
altered sensory perception
-
compromised circulatory status
-
Group 2 products take many forms, but are typically
powered pressure reducing mattresses or overlays.
They are covered for patients with one of three
conditions:
-
Multiple stage II ulcers on the pelvis or trunk
while on a comprehensive treatment program for
at least a month using a Group 1 product, and at
the close of that month, the ulcers worsened or
remained the same. (Monthly follow-up is
required by a clinician to ensure that the
treatment program is modified and followed. This
product is only covered while ulcers are still
present.) OR
-
Large or multiple Stage III or IV ulcers on the
trunk or pelvis (Monthly follow-up is required
by a clinician to ensure that the treatment
program is modified and followed. This product
is only covered while ulcers are still present.)
OR
-
A recent myocutaneous flap or skin graft for an
ulcer on the trunk or pelvis within the last 60
days who were immediately placed on Group 2 or 3
support surface prior to discharge from the
hospital and the patient has been discharged
within last 30 days.
TENS Units
-
TENS units are covered for the treatment of chronic
intractable pain that has been present for at least
three months or more, and in some cases for acute
post-operative pain.
-
Not all types of pains can be treated with a TENS
unit. TENS units have proven ineffective in treating
headaches, visceral abdominal pains, pelvic pains,
and TMJ pains, and therefore Medicare will not pay
for the device when used to treat these conditions.
-
For chronic pain sufferers, Medicare will pay for a
one or two month trial rental to determine if this
device will alleviate the chronic pain. You must
return to your physician exactly 30-60 days after
initial evaluation to authorize the purchase of this
equipment.
-
For acute post-operative pain sufferers, Medicare
will consider rental payment for a maximum of 30
days. Any duration longer than that will require
individual consideration.
Therapeutic Shoes
-
Special therapeutic shoes, inserts, and
modifications can be covered for diabetic patients
with the following foot conditions:
-
previous amputation of a foot or partial foot
-
history of foot ulceration
-
peripheral neuropathy with callus formation
-
foot deformity
-
poor circulation in either foot
Urological Supplies
-
Urinary catheters and external urinary collection
devices are covered to drain or collect urine for a
patient who has permanent urinary incontinence or
permanent urinary retention. Permanent urinary
retention is defined as retention that is not
expected to be medically or surgically corrected in
that patient within 3 months.
<<Back to Top>>
III.
Medicare Supplier Standards
Below is a summary of the standards
Medicare requires of home medical equipment providers.
Our company meets or exceeds all of these standards.
-
A supplier must be in compliance with all applicable
Federal and State licensure and regulatory
requirements.
-
A supplier must provide complete and accurate
information on the DMEPOS supplier application. Any
changes to this information must be reported to the
National Supplier Clearinghouse within 30 days.
-
An authorized individual (one whose signature is
binding) must sign the application for billing
privileges.
-
A supplier must fill orders from its own inventory,
or must contract with other companies for the
purchase of items necessary to fill the order. A
supplier may not contract with any entity that is
currently excluded from the Medicare program, any
State health care programs, or from any other
Federal procurement or non-procurement programs.
-
A supplier must advise beneficiaries that they may
rent or purchase inexpensive or routinely purchased
durable medical equipment, and of the purchase
option for capped rental equipment.
-
A supplier must notify beneficiaries of warranty
coverage and honor all warranties under applicable
State law, and repair or replace free of charge
Medicare covered items that are under warranty.
-
A supplier must maintain a physical facility on an
appropriate site.
-
A supplier must permit CMS (formerly HCFA), or its
agents to conduct on-site inspections to ascertain
the supplier’s compliance with these standards. The
supplier location must be accessible to
beneficiaries during reasonable business hours, and
must maintain a visible sign and posted hours of
operation.
-
A supplier must maintain a primary business
telephone listed under the name of the business in a
local directory or a toll free number available
through directory assistance. The exclusive use of a
beeper, answering machine or cell phone is
prohibited.
-
A supplier must have comprehensive liability
insurance in the amount of at least $300,000 that
covers both the supplier’s place of business and all
customers and employees of the supplier. If the
supplier manufactures its own items, this insurance
must also cover product liability and completed
operations.
-
A supplier must agree not to initiate telephone
contact with beneficiaries, with a few exceptions
allowed. This standard prohibits suppliers from
calling beneficiaries in order to solicit new
business.
-
A supplier is responsible for delivery and must
instruct beneficiaries on use of Medicare covered
items, and maintain proof of delivery.
-
A supplier must answer questions and respond to
complaints of beneficiaries, and maintain
documentation of such contacts.
-
A supplier must maintain and replace at no charge or
repair directly, or through a service contract with
another company, Medicare-covered items it has
rented to beneficiaries.
-
A supplier must accept returns of substandard (less
than full quality for the particular item) or
unsuitable items (inappropriate for the beneficiary
at the time it was fitted and rented or sold) from
beneficiaries.
-
A supplier must disclose these supplier standards to
each beneficiary to whom it supplies a
Medicare-covered item.
-
A supplier must disclose to the government any
person having ownership, financial, or control
interest in the supplier.
-
A supplier must not convey or reassign a supplier
number, i.e., the supplier may not sell or allow
another entity to use its Medicare billing number.
-
A supplier must have a complaint resolution protocol
established to address beneficiary complaints that
relate to these standards. A record of these
complaints must be maintained at the physical
facility.
-
Complaint records must include: the name, address,
telephone number, and health insurance claim number
of the beneficiary, a summary of the complaint, and
any actions taken to resolve it.
-
A supplier must agree to furnish CMS (formerly HCFA)
any information required by the Medicare statute and
implementing regulations.
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All suppliers of DMEPOS and other items and services
must be accredited by a CMS-approved accreditation
organization in order to receive and retain a
supplier billing number. The accreditation must
indicate the specific products and services, for
which the supplier is accredited in order for the
supplier to receive payment for those specific
products and services.
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All DMEPOS suppliers must notify their accreditation
organization when a new DMEPOS location is opened.
The accreditation organization may accredit the
supplier location for three months after it is
operational without requiring a new site visit.
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All DMEPOS supplier locations, whether owned or
subcontracted, must meet the DMEPOS quality
standards and be separately accredited in order to
bill the Medicare. An accredited supplier may be
denied enrollment or their enrollment may be
revoked, if CMS determines that they are not in
compliance with the DMEPOS quality standards.
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All DMEPOS suppliers must disclose upon enrollment
all products and services, including the addition of
new product lines for which they are seeking
accreditation. If a new product line is added after
enrollment, the DMEPOS supplier will be responsible
for notifying the accrediting body of the new
product so that the DMEPOS supplier can be
re-surveyed and accredited for these new products.
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All DMEPOS suppliers must obtain a surety bond in
order to receive and retain a supplier billing
number.
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