CurrentAnthemPolicy G-06112

Reimbursement for Items under Warranty

Governance of Anthem Blue Cross Medi‑Cal reimbursement for repair or replacement of durable medical equipment, supplies, prosthetics, and orthotics during the manufacturer's warranty period; applies to providers serving Anthem Blue Cross Medi‑Cal members in California.

Policy Summary

PayerAnthem

PolicyReimbursement for Items under Warranty

Policy CodePolicy G-06112

Change TypeReview approved: no material changes (09/11/2025)

Effective DateSep 11, 2025

Next Review Date

Key ActionProviders must meet authorization and medical necessity guidelines and use proper billing and submission practices when requesting reimbursement.

SourceLink

POLICY UPDATE CHANGES

09/11/2025 - Review approved: no changes

04/06/2023 - Review approved and effective: removed prudent buyer language under reimbursement consideration

4item categories listed (DME, supplies, prosthetics, orthotics)

Provider must supplymanufacturer warranty information to members

Manufacturer/distributorresponsible for repair, replacement, and shipping/delivery fees during warranty

Reimbursement limitedto cost of manufacturer's reduced-price offer when applicable

Reimbursement During Manufacturer's Warranty

Policy Summary

PayerAnthem

PolicyReimbursement for Items under Warranty

Policy CodePolicy G-06112

Change TypeReview approved: no material changes (09/11/2025)

Effective DateSep 11, 2025

Next Review Date

Key ActionProviders must meet authorization and medical necessity guidelines and use proper billing and submission practices when requesting reimbursement.

SourceLink

On This Page

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Warranty-period reimbursement criteria

The health plan generally does not reimburse for repair or replacement of items during the manufacturer's warranty period; manufacturer/distributor responsibility and limited exceptions are outlined below.

The health plan does not allow reimbursement for repair or replacement of rented or purchased items during the warranty period designated by the applicable manufacturer unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Applies to durable medical equipment, supplies, prosthetics, and orthotics.

ALL of the following

Repair the item or provide an acceptable replacement item.
Pay all fees associated with shipment of the defective item.
Pay all fees associated with delivery of the repaired item.
If the health plan has reimbursed the provider during the warranty period, the health plan may recoup fees from the manufacturer and/or distributor holding the warranty.
Care providers must supply members with information concerning the manufacturer's warranty for all items dispensed to members.

Exceptions / Considerations

Health plan will consider reimbursement for replacement through another manufacturer after review only when both the member and the provider deem the manufacturer's replacement unacceptable. Design, materials, measurements, fabrication, testing, fitting, and training for the replacement are included in item reimbursement and are not separately reimbursable.
If the manufacturer offers an acceptable reduced-price replacement but the member prefers a different full-price item or the provider did not use the reduced-price offer, reimbursement is allowed only up to the cost of the reduced-price item.
If the manufacturer offers an acceptable replacement but imposes a charge or pro rata payment, the health plan allows reimbursement for the partial payment imposed by the manufacturer, subject to approval.

Authorization, Documentation, and Provider Responsibilities

Documentation Required

Obtain authorization, document medical necessity, and bill correctly

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and comply with billing and submission guidelines. Use industry-standard CPT, HCPCS, and/or revenue codes that are fully supported by the medical record and/or office notes. Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, and the plan may recover or recoup claim payment.

Ensure prior authorization is obtained when required and documentation supports medical necessity for the specific procedure and diagnosis.
Bill using CPT, HCPCS, and/or revenue codes; documentation in the medical record must fully support billed codes.
Follow the plan’s billing and submission guidelines; noncompliance may lead to claim rejection, denial, or recoupment.

OpenPayer

Reimbursement for Items under Warranty

Reimbursement During Manufacturer's Warranty

Coding and Billing Codes

Authorization, Documentation, and Provider Responsibilities

Policy Definitions and References