CurrentBlue Cross Blue Shield - KansasPolicy N/A

Home Medical Equipment (HME) reimbursement and supplier obligations

This document governs billing, reimbursement, rental vs purchase, pre-certification, supplier responsibilities, and contract/member exclusions for home medical equipment provided to Blue Cross and Blue Shield of Kansas members.

Policy Summary

PayerBlue Cross Blue Shield - Kansas

PolicyHome Medical Equipment (HME) reimbursement and supplier obligations

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain pre-certification when required by the member's contract before delivering home medical equipment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10 daysmaximum procurement time for non-routinely available items

24-hourorder acceptance availability requirement for suppliers

monthlyrental credit applied up to MAP or provider charge

exclusionsTEN may be excluded by member contract

prohibitedautomatic shipments prohibited without consent

Coverage Criteria and Supplier Billing Rules

HME coverage criteria and supplier billing rules

Coverage and billing rules summarized from the policy document.

Pre-certification required when specified by member contract; pre-approval must be obtained before delivery.

Suppliers will be informed of pre-certification requirements when provider verifies member benefits.

Member contract exclusions

Some member contracts may exclude items or services in their entirety or parts thereof (example: total enteral nutrition).
Suppliers and billing must follow member contract terms.

Rental-to-purchase financial rule: On items designated by BCBSKS, monthly rental may be applied toward the normal retail price up to the Maximum Allowable Price (MAP) or provider's charge, whichever is less. Once rental allowables meet the purchase price, BCBSKS and supplier obligations for that item end.

Exception: this provision does not apply to ventilators or oxygen/oxygen equipment; monthly rental may continue for those items.

Policy Summary

PayerBlue Cross Blue Shield - Kansas

PolicyHome Medical Equipment (HME) reimbursement and supplier obligations

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain pre-certification when required by the member's contract before delivering home medical equipment.

SourceLink

On This Page

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ALL of the following

Maintain adequate inventory and ensure supplies are immediately available in the contracting supplier's warehouse.
Obtain non-routinely available items as rapidly as possible, not to exceed ten days unless delayed by the manufacturer.
Accept orders 24 hours a day for medical equipment, related products and services.
Deliver and service medical equipment and related products ordered for or furnished to members; perform in-service training for BCBSKS employees if required.
Ensure appropriate insurance coverage (medical liability, accident, automobile, workers compensation, comprehensive general liability and professional malpractice) for employees or undertake equivalent obligations.
Before billing for ongoing supplies and rental of DME/HME, verify items are still in use and meet medical necessity requirements.
Do not automatically ship supplies without the member's prior written consent.

ALL of the following

Services or procedures that are integral to the total price of equipment or supplies (examples: record entries, evaluation of reports, advice/counseling, containers/labeling, shipping within normal trade area, setup, repair/maintenance of normal wear on rental equipment, billing fees, taxes, fittings/adjustments, office overhead) are considered content of service and are not separately reimbursed.
Appropriate all-inclusive HCPCS codes must be used when available.

Billing and supplier compliance note

Suppliers will be told of pre-certification requirements when providers call to verify member benefits; supplier billing must adhere to member contract terms and the content-of-service inclusions above.

Coding and Rental-to-Purchase Rules

All-inclusive HCPCS codingHCPCS

No codes listed

Rental-to-Purchase Threshold (inv-03)

Rental credit appliedMonthly rental is allowed toward the normal retail (purchase) price up to the Maximum Allowable Price (MAP) or the provider's charge, whichever is less.

End of obligationsWhen accumulated rental allowables equal the purchase price, Blue Cross and Blue Shield of Kansas and the supplier’s obligations for that item end.

ExceptionsThe rental-to-purchase provision does not apply to ventilators or oxygen/oxygen equipment; monthly rental may continue for those items.

Pre-Certification and Supplier Obligations

Prior Authorization

Pre-certification required before delivery when specified by member contract

Certain members' contracts require pre-certification of home medical equipment. Pre-approval from Blue Cross and Blue Shield of Kansas must be obtained in writing before delivery; suppliers will be notified of this requirement when the provider verifies member benefits.

Obtain written pre-certification from BCBSKS before delivering HME when member contract requires it.
Verify member benefits by phone or system; suppliers will be informed if pre-certification is required.

Definitions

Content of Service (inv-05)

DefinitionContent of Service: services and procedures considered integral to the total price of the equipment or supply for which separate reimbursement is not recognized.

Included examplesEntries into the patient’s records; evaluation of test reports; advice, counseling or information provided with the service.

Operational items includedContainers and labeling; shipping or delivery within normal trade area; setup of equipment; repair and maintenance for normal wear on rental equipment.

Administrative overheadBilling fees, taxes, fittings/adjustments/video monitoring, and office overhead items (malpractice insurance, telephones, personnel) are considered content of service.

Coding noteAppropriate all-inclusive HCPCS codes must be used when available.

Rental in Lieu of Purchase (inv-06)

DefinitionRental in Lieu of Purchase: monthly rental payments may be credited toward the purchase price up to the MAP or provider’s charge.

Credit applicationMonthly rental is applied toward the normal retail (purchase) price until rental allowables meet the purchase price.

Termination of obligationsOnce rental allowables meet the purchase price, BCBSKS and the supplier’s obligations for that item end.

ExceptionsProvision does not apply to ventilators or oxygen/oxygen equipment; monthly rental may continue for those items.