Member Reimbursement
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Governance of member reimbursement requests to Aspirus for services/items paid out-of-pocket that may be covered under the member's contract; primarily affects Aspirus Medicare product members and providers involved in reimbursement claims.
No material clinical or coverage changes in this revision.
Reimbursement Coverage Criteria
Reimbursement coverage criteria and exclusions
Covered when ALL of the following are met:
Coding and Rate
| No specific CPT/HCPCS/ICD-10 codes listed; codes provided are informational and not a guarantee of coverage. |
Actions Required for Reimbursement
Provider requirements and submission rules for reimbursement
Prior authorization is not required. Providers must be Medicare providers; Aspirus will not reimburse for services from providers who have opted out of Medicare. For DME and supplies, Aspirus requires a written and signed order from the member's provider before purchase. Members (or providers submitting on their behalf) must submit required documentation (Claim Reimbursement Form recommended, copies of bills/receipts/itemized statements, and medical records or provider orders as applicable) to Aspirus within 12 months of the date of service. Aspirus will pay at rates no greater than Original Medicare and will only pay Aspirus's share of the cost (member remains responsible for copay, deductible, or coinsurance).
- Prior authorization: Not required.
- Provider must be a Medicare provider; no reimbursement if provider opted out of Medicare.
- Written, signed order required before purchase to qualify for DME and supplies reimbursement.
- Submit Claim Reimbursement Form (recommended), itemized bills/receipts, and medical records/provider orders within 12 months of service.
- Reimbursement paid at rates no greater than Original Medicare; Aspirus pays only its share (member responsible for copay/deductible/coinsurance).
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.