CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Durable Medical Equipment (DME) payment and rental policy

Governance of coverage, rental, repair, replacement, and billing practices for durable medical equipment for Blue Cross & Blue Shield of Rhode Island members (Commercial and Medicare Advantage products). Affects BCBSRI members, DME suppliers, and providers submitting claims or authorizations.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDurable Medical Equipment (DME) payment and rental policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2021

Next Review DateN/A

Key ActionFollow CMS rent-to-purchase and interruption rules: bill monthly up to 10 months (then considered purchased) and submit a new authorization and documentation if rental interruption exceeds 60 consecutive days.

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POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10-monthrental period considered purchase after

1/10 purchasestandard rental billing fraction

60 daysmax interruption without new rental

Omnipod Dashitems covered via pharmacy (example)

used/private sellers

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non-reimbursable sources

Coverage and Billing Criteria for DME

DME coverage and billing criteria

Coverage determinations and rules

Rent-to-purchase: DME rentals are for a period of ten (10) continuous months, after which the item is considered purchased; monthly rental charge is generally one‑tenth (1/10) of the purchase price per month; charges beyond ten consecutive months are non-billable; oxygen and oxygen equipment are excluded from the rent-to-purchase cap as designated by CMS (Category indicator 'OX').

Interruption of rental period: temporary interruptions up to 60 consecutive days do not start a new rental period; interruptions greater than 60 consecutive days may allow a new 10‑month rental period only if the supplier submits a new prescription/order, new medical necessity documentation, and a statement explaining the reason for the interruption; supplier must maintain documentation and BCBSRI may audit records.

Repairs: repair of DME is covered when the original equipment was ordered by a physician and the equipment continues to be medically necessary; repairs and supplies for rental equipment used during the rental period are included in the rental allowance (with limited exceptions such as certain CPAP/BiPAP supplies); loaner rental during repair is covered.

Replacement: BCBSRI follows CMS guidelines for reasonable useful lifetime (typically ~5 years); replacement is covered when medically necessary due to change in condition, growth, loss of manufacturer support, cost to repair comparable to replacement, or manufacturer recall; replacement rules vary depending on purchase/rental status and warranty.

Maintenance and service: routine periodic servicing (cleaning, testing, regulating, checking) is not covered except for oxygen equipment; required testing/maintenance is the supplier/provider responsibility and associated costs are not reimbursed to the member.

Convenience, duplicate, and deluxe items: items prescribed primarily for convenience, duplicate items for multiple locations, or 'deluxe'/'enhanced' equipment beyond basic functional needs are not covered.

Member‑purchased items: members may submit purchases for reimbursement only with a physician order and receipt that includes product description and HCPCS code; vendor receipt and documentation of diagnosis/medical necessity are required.

Non‑covered items and situations: items that do not meet the CMS definition of DME, repairs/replacements covered by the manufacturer warranty, and repairs/replacements due to abuse, neglect, loss, or theft are not covered.

Billing rules and supplier responsibilities: monthly rentals should be billed with a unit of 1 per calendar month; suppliers must retain documentation and may be audited; BCBSRI does not reimburse for extended warranties.

DME coverage and operational criteria

Coverage stance and criteria for DME and related supplies as stated in this portion of the policy:

Benefit variability: benefits may vary between groups/contracts; refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable coverage details.

DME definition requirement: the item must meet the CMS definition of Durable Medical Equipment (physician‑ordered, primarily and customarily used to serve a medical purpose, able to withstand repeated use, not useful in the absence of illness/injury, and for use in the home) to be covered.

Rent‑to‑purchase: rental is billed monthly up to 10 months; after 10 months the item is considered purchased and rental payment will cease; the rental allowance will not exceed the purchase allowance; BCBSRI follows CMS rent‑to‑purchase guidelines.

Repair and replacement criteria: repair or replacement may be considered when medically necessary; replacement typically when item is irreparably damaged or no longer meets the member's needs; manufacturer‑warrantied repairs/replacements are the manufacturer's/provider's responsibility; repairs due to abuse/neglect/loss are not covered.

Coding, Pricing, and Rental Rules

Member-purchased items coding requirementHCPCS

HCPCS required on receipt

Vendor receipt must include product description and HCPCS code when members submit purchases for reimbursement.

Coding applicabilitymixed

Not applicable / no coding specified in this section

Monthly rental pricing rule

Monthly rental pricing ruleStandard monthly rental = one-tenth (1/10) of the purchase price per month (billing monthly).

Billing unitMonthly rentals should be billed as one unit per calendar month.

Allowance capThe rental allowance for an item will never exceed the purchase allowance for that item.

Rent-to-purchase cap exception

OX category exceptionOxygen and oxygen equipment (CMS category indicator 'OX') are excluded from the rent-to-purchase cap and are priced at the rental allowance.

Reference sourceItems designated by CMS as Oxygen/Oxygen Equipment are identified on the CMS DME Fee Schedule with category indicator 'OX'.

Prior Authorization and Provider Responsibilities

Note

Prior Authorization

Not applicable

Prior Authorization

Authorization on interruption or replacement

If an interruption of rental use is greater than 60 consecutive days and the item requires authorization, a new authorization request must be completed. The DME supplier must maintain documentation including the physician’s new prescription/order, supporting medical necessity documentation, and a statement explaining the reason for the interruption. BCBSRI may request medical records for review if frequent interruptions in excess of 60 days are observed. Failure to produce requested documentation may result in denial or retraction of payment.

Interruptions <= 60 consecutive days do not start a new rental period.
Interruptions > 60 consecutive days may initiate a new 10-month rental period if documentation is provided: prescription, medical necessity documentation, and an explanation of the interruption.

Prior Authorization

Definitions and CMS Category Indicators

DME / DMEPOS

DMEPOS alignmentBCBSRI follows CMS Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) guidelines for Commercial and Medicare Advantage products.

Use when no specific policyIn the absence of a medical or payment policy for a specific DME item, CMS DMEPOS guidance applies.

ScopeGuidance governs rental, repair, replacement, maintenance, billing, and coverage practices for DME items.

CMS DME Fee Schedule category indicators

OX = Oxygen/Oxygen EquipmentCMS DME Fee Schedule category indicator 'OX' identifies Oxygen and Oxygen Equipment; these items are excluded from the rent-to-purchase cap.

FS = Frequent and Substantial ServicingItems with category indicator 'FS' on the CMS DME Fee Schedule are classified as Frequent and Substantial Servicing and are considered continuous rental items.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDurable Medical Equipment (DME) payment and rental policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2021

Next Review DateN/A

SourceLink

On This Page

Non‑covered sources and items: members are not reimbursed for used items or items purchased from private sellers or online auction sites; items obtained from non‑plan contracted providers or certain online retailers may be non‑covered for Medicare Advantage members; repairs to items purchased outside warranty are member responsibility.

Insulin pump coverage channeling: Insulet Omnipod Dash (effective 7/1/2021) is covered under the pharmacy benefit if the member has pharmacy coverage and is dispensed through the pharmacy (no authorization required); other branded insulin pumps are covered under the DME benefit and do not require authorization.

Change in insurance carrier during rental: if a member changes carriers after the third rental month with no coverage lapse, a participating BCBSRI DME supplier will be reimbursed by BCBSRI for remaining rental months only; supplier may not bill the member for charges after BCBSRI has paid the 10‑month rental; allowable differences between carriers may exist.

Follow interruption guidelines: interruption of rental period rules (60‑day threshold, documentation requirements) apply as described in the rental/interruption sections.

Impact on rent-to-purchaseOX-designated items may be rented without being subject to the 10-month rent-to-purchase cap described for other DME items.

Rental duration threshold

Rental duration thresholdDME rentals billed monthly for up to ten (10) continuous months; after 10 months the item is considered purchased.

Non-billable beyond thresholdCharges for monthly rentals beyond ten consecutive months are non-billable.

Transfer/remaining balance ruleIf a rental device is replaced before 10 months (e.g., ineffective device upgraded), remaining rental months of the original device may be applied toward the replacement for the remainder of the 10-month period.

Authorization for insulin pumps

Certain insulin pumps are covered under the pharmacy benefit and do not require prior authorization when dispensed through the pharmacy. Specifically, the Insulet Omnipod Dash is covered under the member’s pharmacy benefit (if the member has pharmacy benefits through BCBSRI), is only available through the pharmacy per the manufacturer’s distribution channel, and does not require authorization. Other branded insulin pumps are covered under the member’s DME benefit and generally do not require authorization. For questions, members should contact customer service and providers may contact the provider call center.

Insulet Omnipod Dash: pharmacy benefit, pharmacy-only distribution, no prior authorization required (effective 2021-07-01).
Other branded insulin pumps: covered under DME benefit and do not require prior authorization.

Billing Rule

Rent-to-purchase billing

BCBSRI follows CMS rent-to-purchase guidelines for DME rentals. Rental DME is billed monthly for up to a 10-month period; after 10 months the item is considered purchased and rental billing ends.

CR = Custom/RareItems with category indicator 'CR' on the CMS DME Fee Schedule are designated as custom or rare and are treated per CMS rules.

Durable Medical Equipment (DME)

CMS DME definitionDurable Medical Equipment (DME) is physician-ordered equipment providing therapeutic benefit, primarily and customarily used to serve a medical purpose, able to withstand repeated use, not useful in the absence of illness or injury, and intended for use in the home.

Order requirementDME must be ordered by a physician to be considered under the DME definition.

Purpose and useDME may facilitate treatment or rehabilitation to restore or improve function based on the member's medical condition(s).