CurrentAnthemPolicy G-06112

Reimbursement for Items under Warranty

Governs reimbursement for repair or replacement of rented or purchased items during the manufacturer's warranty period for Anthem members; applies to providers submitting claims to the health plan.

Policy Summary

PayerAnthem

PolicyReimbursement for Items under Warranty

Policy CodePolicy G-06112

Change TypeNo material changes

Effective DateSep 11, 2025

Next Review Date

Key ActionFollow standard correct coding and ensure authorization and medical necessity guidelines are met to avoid claim rejection, denial, or recoupment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

warranty periodreimbursement disallowed during

recoupmentrecoupment allowed

alternative replacementreimbursement considered

reduced-price capreimbursement limit

no changesreview status

Warranty Reimbursement Policy and Exceptions

Warranty reimbursement policy and exceptions

Covered when ALL of the following are met:

Do not reimburse repair or replacement of rented or purchased items during the manufacturer's warranty period unless provider, state, federal, or CMS contracts/requirements indicate otherwise.

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

Manufacturer or distributor responsibility: repair the item or provide an acceptable replacement and cover all shipment and delivery fees.

If the plan reimburses the provider during the warranty period, the plan may recoup fees from the manufacturer or distributor holding the warranty; providers must supply members with information about the manufacturer's warranty for all dispensed items.

Exceptions and reimbursement considerations

Policy Summary

PayerAnthem

PolicyReimbursement for Items under Warranty

Policy CodePolicy G-06112

Change TypeNo material changes

Effective DateSep 11, 2025

Next Review Date

Key ActionFollow standard correct coding and ensure authorization and medical necessity guidelines are met to avoid claim rejection, denial, or recoupment.

SourceLink

On This Page

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The plan will consider reimbursement for replacement from another manufacturer only after review and only when both the member and the member's care provider deem the manufacturer's replacement unacceptable; design, fitting, training, and related services 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 selects a different full-price replacement or the provider did not use the reduced-price offer, reimbursement is limited to the cost of the reduced-price item.

If the manufacturer offers an acceptable replacement but requires a charge or pro rata payment, the plan may allow reimbursement for the partial payment imposed by the manufacturer, subject to approval.

Providers are required to supply members with information concerning the manufacturer's warranty for all items dispensed to members.

Coding and Reimbursement Limits

Standard correct codingmixed

CPT/HCPCS/Revenue

Services and items should be billed with appropriate CPT, HCPCS, and/or revenue codes supported by documentation.

Reimbursement limit when reduced-price offered (inv-03)

Policy ruleIf the manufacturer offers an acceptable reduced-price replacement but the member selects a different full-price replacement or the provider did not use the reduced-price offer, reimbursement is limited to the cost of the reduced-price item.

ScopeApplies when an acceptable reduced-price replacement is offered by the manufacturer and an alternative full-price replacement is chosen by the member or provider.

Related allowanceIf manufacturer offers acceptable replacement but imposes a charge or pro rata payment, plan may reimburse for the partial payment subject to approval.

Action for providersDocument the manufacturer’s reduced-price offer and member/provider choice to support claims when reimbursement is limited.

Provider Coding, Authorization, and Billing Responsibilities

Denial Risk

Coding, authorization, and billing responsibilities — risk of denial or recoupment

Follow standard correct coding and ensure all services meet applicable authorization and medical necessity requirements. Use industry-standard CPT, HCPCS, and/or revenue codes that are fully supported in the medical record; failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, recovery/recoupment of payment, or reimbursement adjustments.

Bill services with CPT, HCPCS, and/or revenue codes supported by documentation.
Ensure authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member’s state of residence are met.
Adhere to applicable provider, state, federal, or CMS mandates that supersede these policies.

Referenced Definitions

Definitions referenced (inv-05)

Definitions referencedGeneral Reimbursement Policy Definitions (see policy definitions section).

Warranty periodThe manufacturer-designated warranty period during which the plan generally does not reimburse repair or replacement.

Manufacturer responsibilityManufacturer/distributor responsible for repair or acceptable replacement and associated shipping/delivery fees during warranty.

Alternative replacementReplacement from another manufacturer may be considered only when manufacturer’s replacement is deemed unacceptable by member and provider.