CurrentAlaska MedicaidPolicy N/A

Shipping Reimbursement for Durable Medical Equipment (DME)

Rules for Alaska Medicaid reimbursement of shipping associated with durable medical equipment (DME) including custom, customized/optimally configured, and specialized/unique items; applies to DME providers and members in Alaska.

Policy Summary

PayerAlaska Medicaid

PolicyShipping Reimbursement for Durable Medical Equipment (DME)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionInclude estimated shipping costs and method, and indicate warranty period when requesting service authorization for repair or replacement parts.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50 milesminimum distance for shipping claims

$250manufacturer-to-dispensing threshold

50%max repair+shipping % of replacement

10 morental timeframe (capped rentals dispensed new)

6 morental timeframe (other scenarios)

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Shipping Coverage Criteria

Primary shipping coverage rules

Covered when ALL of the following are met:

Shipping is considered when the provider-to-member distance is 50 miles or more and there is no closer provider from which the member can obtain the item(s).

Shipping claims submitted under A9999CG must be for the most cost-effective shipping method.

Shipping is covered from the dispensing provider to the recipient when the item is not available in the recipient's local area.

Shipping is reimbursed from the recipient to the dispensing provider for repair of recipient-owned equipment when the service is not available in the recipient's local area.

Shipping from manufacturer to dispensing provider is covered for customized or optimally configured DME repair and replacement parts that are specialized or unique to the recipient’s equipment when the final unaltered purchase price exceeds $250; shipping reimbursement must be included on the same claim as the repair or replacement parts.

Shipping from the dispensing provider to the manufacturer is not covered.

Repair/replacement authorization rules

Authorization and documentation required for manufacturer shipping and repairs:

Service authorization requests for repair or replacement parts must include the estimated shipping costs from the manufacturer to the dispensing provider and the method of shipping.

The service authorization request must indicate the warranty period for the item(s) needing repair.

Shipping is covered only if Alaska Medicaid would cover the repair or replacement.

For patient-owned equipment that is no longer under warranty, shipping to and from the manufacturer may be considered only if: (1) the cost of repair plus estimated shipping is less than 50% of the replacement cost, AND (2) the repair must be completed by the manufacturer because specialized equipment or expertise is unavailable in Alaska, AND (3) the estimated shipping costs are included in the service authorization request.

Trials, rentals, and amendment-to-purchase rules

Rules for trials, rentals, and requests to amend rental to purchase status:

Estimated return shipping costs must be indicated on a service authorization request prior to dispensing trial equipment; the authorization must include the equipment being trialed, length of trial, rationale for trial, alternatives considered, and why no local trial occurred.

Return shipping for new or used rental items will not be considered.

Amendment-to-purchase considerations (capped rentals dispensed new)

If a capped rental item was dispensed new and received service authorization for the full capped rental timeframe, an amendment request must state the item was in rental status for 10 or more months and provide the rationale for the amendment.

Amendment-to-purchase considerations (other scenarios)

For rental items that were new when dispensed and authorized for the full 10-month rental timeframe, an amendment request must identify the item was in rental status for 6 or more months and provide rationale.

Billing and Coding

Shipping billing codeHCPCS

A9999CG

Shipping claims submitted under this code must be for the most cost-effective shipping method.

Manufacturer-to-dispensing-provider shipping threshold

Threshold amount$250 (final unaltered purchase price + applicable percentage as stated in regulations)

Condition for applicabilityApplies to manufacturer-to-dispensing-provider shipping for customized/optimally configured DME repair or replacement parts that are specialized or unique to a recipient's equipment

Claim requirementShipping reimbursement request must be included on the same claim as the repair or replacement parts

Documentation required with prior authorizationEstimated shipping costs and method must be included in the service authorization request

Provider Requirements and Authorization Guidance

Prior Authorization

Service authorization must include estimated shipping, method, and warranty; ship on same claim as parts

When requesting service authorization for repair or replacement parts that require manufacturer shipping, include the estimated shipping cost and the method of shipping in the authorization request; the shipping reimbursement must be submitted on the same claim as the repair or replacement parts. Also indicate the warranty period for the item(s) needing repair. Shipping is covered only if Alaska Medicaid would cover the repair or replacement. For patient‑owned equipment out of warranty, include estimated shipping and ensure repair plus shipping is less than 50% of replacement cost and that the manufacturer must complete the repair.

Include estimated shipping costs and method in the service authorization request.
Submit shipping reimbursement on the same claim as the repair/replacement parts when manufacturer-to-dispensing-provider shipping is requested.
Indicate the warranty period in the service authorization.
Shipping covered only if Alaska Medicaid would cover the repair or replacement.
For patient‑owned out-of-warranty equipment, confirm repair + shipping < 50% of replacement cost and that manufacturer must perform the repair; include estimated shipping in the authorization.

Defined Terms

Custom

DefinitionAn item that is so uniquely constructed that the item cannot be grouped with other items for pricing purposes.

ExamplesCustom tracheostomy tubes; wheelchair base K0013 (uniquely constructed or substantially modified)

Pricing implicationCannot be grouped with other items for pricing; may be paid in one lump sum under Medicare criteria when applicable

Customized/Optimally Configured

DefinitionAn item that may contain custom parts and/or was modified, bent, molded, or shaped to meet the medical needs of the recipient.

ExamplesCustomized tracheostomy tubes; manual and power wheelchairs (excluding wheelchair base K0013); enclosed beds

Policy Summary

PayerAlaska Medicaid

PolicyShipping Reimbursement for Durable Medical Equipment (DME)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionInclude estimated shipping costs and method, and indicate warranty period when requesting service authorization for repair or replacement parts.

SourceLink

On This Page

For items dispensed in used condition with authorization for the full 10-month or capped rental timeframe, an amendment request must identify the item was in rental status for 6 or more months and provide rationale.

For items dispensed without prior authorization (for example, dually eligible Medicare/Medicaid members where Medicare did not require authorization), providers may request authorization for purchase minus any Medicare and Medicaid reimbursements after Medicare rental reimbursement ceases.

Service authorization requests where Medicare ceased rental reimbursement receive higher priority; authorization requests should include details explaining why Medicare reimbursements ceased.

Prior Authorization

Document rental duration and rationale for amendment-to-purchase requests; prioritize Medicare cessation cases

When requesting an amendment from rental to purchase, document the rental duration and rationale in the service authorization; include details explaining why Medicare rental reimbursement ceased where applicable. Authorization requests where Medicare ceased rental reimbursement receive higher priority.

Document length of time item was rented and rationale for amendment request.
If Medicare ceased rental reimbursement, include details explaining why reimbursements stopped.
Requests under the scenario where Medicare ceased rental reimbursement receive higher priority.

Configurational noteSpecific configurational needs are met using cushions, options, or accessories (prefabricated or custom fabricated) which can be added to standard bases

Specialized or Unique

DefinitionAn individual item designed for a particular individual and for a specific purpose where the item is the only one of its kind.

ExamplesCustom-fitted wheelchair cushions (e.g., pin-dot molded seat back); custom molded diabetic shoe inserts

Use caseItems tailored to a single recipient and not interchangeable with standard products