Home Medical Equipment (HME) reimbursement and supplier obligations
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria and Supplier Billing Rules
HME coverage criteria and supplier billing rules
Coverage and billing rules summarized from the policy document.
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.
Exception: this provision does not apply to ventilators or oxygen/oxygen equipment; monthly rental may continue for those items.
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.
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
| No codes listed |
Pre-Certification and Supplier Obligations
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
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