CurrentBlue Cross Blue Shield - KansasPolicy N/A

Home Medical Equipment — Supplier Obligations and Reimbursement

Governance of reimbursement, supplier responsibilities, rental vs purchase, pre-certification, exclusions, and availability requirements for home medical equipment provided to Blue Cross and Blue Shield of Kansas members.

Policy Summary

PayerBlue Cross Blue Shield - Kansas

PolicyHome Medical Equipment — Supplier Obligations and Reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain written pre-certification from BCBSKS 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 daysmax time to obtain non-routine items

24-hourorder acceptance availability

monthlyrental toward purchase

ventilators & oxygenrental-to-purchase excluded

consent reqauto-ship of supplies

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Coverage limits, exclusions, and member financial responsibility

Financial and coverage limitations specified in member contracts and supplier billing responsibilities:

Contract exclusions: Certain services are excluded when the contracting provider is not licensed/certified to perform them.

Member contract exclusions

Some member contracts may exclude an item or service in its entirety or parts of the service (example: total enteral nutrition).

Indemnified amounts: When a member contract limits the dollar amount reimbursable for a service, any balance beyond that amount is the member's responsibility.

Deluxe features: Reimbursement is based on the standard item; any member choice of deluxe features is the member's financial responsibility and requires a signed waiver before the service is rendered.

Coverage termination: If the member drops coverage or switches carriers, BCBSKS obligations end and the supplier may bill the patient or retrieve the equipment.

Rental, availability, and supplier obligations

Rental, purchase, and supplier operational coverage rules:

Rental toward purchase: For items designated by BCBSKS, monthly rental applies toward the normal retail price up to the MAP or provider's charge, whichever is less. Once rental allowables meet the purchase price, BCBSKS and supplier obligations end for that item. This provision does not apply to ventilators or oxygen/oxygen equipment (monthly rental may continue).

Availability and performance: The contracting supplier must maintain adequate inventory with items immediately available in the supplier's warehouse; obtain non-routine items as rapidly as possible (not to exceed 10 days unless delayed by manufacturer); accept orders on a 24-hour basis; deliver and service equipment; perform in-service training if required; and maintain required insurance coverages.

Supplies and billing practices: Before billing for ongoing supplies and rental, the supplier must ensure items remain in use and meet medical necessity requirements; automatic shipment of supplies is prohibited without the member's prior written consent.

Coding and billing details

All-inclusive HCPCS usageHCPCS

No codes listed

Rental toward purchase limit

Monthly rental allowanceMonthly rental is allowed toward the normal retail purchase price for BCBSKS‑designated items.

Cap on rental toward purchaseRental applied toward purchase is capped at the MAP or the provider's charge, whichever is less.

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

Exception — ventilators and oxygenProvision excluding ventilators and oxygen/oxygen equipment: the rental‑toward‑purchase rule does not apply and monthly rental may continue.

Pre-certification and supplier/provider responsibilities

Prior Authorization

Prior Authorization Required

Certain members' contracts require pre-certification (prior authorization) for home medical equipment. The pre-approval from Blue Cross and Blue Shield of Kansas, Inc. (BCBSKS) must be obtained and confirmed before delivery or dispensing of equipment.

Pre-certification (prior authorization) must be obtained before delivery or provision of equipment.
Suppliers and providers should verify member benefits and pre-certification requirements by calling BCBSKS prior to dispensing.
Failure to obtain required pre-approval may result in denial of payment or member liability.

Key definitions used in this policy

Content of Service

Definition’Content of service’ are services or procedures integral to the total price of equipment or supplies where separate reimbursement is not recognized.

Common inclusionsExamples include entries into patient records; evaluation of test reports; advice, counseling or information provided with the service; and setup of equipment.

Operational inclusionsAlso includes shipping or delivery within normal trade area, repair and maintenance for normal wear on rental equipment, fittings and adjustments, and video monitoring.

Administrative inclusionsBilling fees, taxes, containers and labeling, and items of office overhead (e.g., malpractice insurance, telephones, personnel) are considered content of service.

Coding noteAppropriate all‑inclusive HCPCS codes must be used when available; separate reimbursement for these items is not recognized.

MAP / rental allowance

MAP definedMAP is the maximum allowable/presumptive retail or contracted allowable used to cap the rental allowance toward a purchase price.

How MAP is appliedFor BCBSKS‑designated items, monthly rental toward purchase is limited to the MAP or provider charge, whichever is less.

Interaction with provider chargeIf the provider's charge is less than MAP, the provider charge becomes the cap on rental toward purchase.

Outcome when cap reachedWhen rental allowables reach the capped purchase price (MAP or provider charge), rental obligations end (except where excluded).