CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Durable Medical Equipment (DME) — general guidelines (rent-to-purchase, repair, replacement, maintenance)

Provides Blue Cross & Blue Shield of Rhode Island guidelines for durable medical equipment (DME) reimbursement and administration for Commercial and BlueCHiP for Medicare products; follows CMS DMEPOS rules when no specific BCBSRI medical policy exists.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDurable Medical Equipment (DME) — general guidelines (rent-to-purchase, repair, replacement, maintenance)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2014

Next Review DateN/A

Key ActionIf a rental interruption exceeds 60 consecutive days, obtain a new prescription, new medical necessity documentation, and a vendor statement describing the interruption to initiate a new 10-month rental period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10 monthsstandard rent-to-purchase rental period

60 daysmaximum interruption length that does NOT start a new rental period

5 yearstypical reasonable useful lifetime for replacement considerations

Policy Snapshot

Durable Medical Equipment (DME) — general guidelines (rent-to-purchase, repair, replacement, maintenance). This policy provides Blue Cross & Blue Shield of Rhode Island (BCBSRI) guidelines for reimbursement and administration of DME for Commercial and BlueCHiP for Medicare products. It addresses general rules for rent-to-purchase, repair, replacement, maintenance, and member-purchased items and follows Centers for Medicare and Medicaid Services (CMS) definitions and guidance for DME. Key program thresholds include a standard rent-to-purchase period of 10 months and an interruption grace period of 60 days. The policy effective date is 2014-12-01, with last review 2020-04-10.

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Medical Necessity & Coverage Rules

In cases where BCBSRI does not have a specific medical policy for a particular DME item, BCBSRI follows the CMS Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) guidance. This approach means CMS definitions, rent-to-purchase rules, and other CMS DMEPOS payment and coverage provisions serve as the default standards for coverage determinations and administration unless BCBSRI has an item-specific policy.

Durable Medical Equipment — Administrative Medical Necessity Criteria

Covered when the following administrative and operational conditions are met:

Billing and supplier change rules

A change in supplier does not restart the 10‑month rental period; the remaining rental months are payable to the supplier providing the item in the 10th month.
Monthly rental pricing guideline: general rule is one‑tenth (1/10) of the purchase price per month.

Exclusions / non‑covered situations

DME items that do not meet the CMS definition of durable medical equipment are non‑covered.
BlueCHiP for Medicare members must obtain DME from plan‑contracted providers; DME from non‑contracted providers and certain online purchases are non‑covered for BlueCHiP for Medicare.
Commercial members are not reimbursed for used items or items purchased from private sellers/auction sites; members purchasing from online retailers must meet receipt and physician order requirements and used items/private seller purchases are not reimbursable.

Replacement criteria

Replacement is covered when the item is required due to a change in the member's medical condition, the equipment no longer meets functional needs due to physical changes (e.g., growth or significant weight change), an upgrade is required and manufacturer no longer supports the item, or cost to replace is comparable to repair.
Replacement batteries are covered for operation of a device; hearing aid batteries are excluded.

Billing, Documentation & Audit Requirements

Documentation Required

Documentation required to initiate a new rental after >60-day interruption

If an interruption in use exceeds 60 consecutive days, the DME vendor must supply a new prescription, new medical necessity documentation, and a statement describing the reason for the interruption to begin a new 10-month rental.

Billing Rule

Monthly rental billing unit

Claims for monthly rentals should include a unit of 1 per month; one month equals one calendar month.

Billing Rule

Rent-to-purchase pricing rule

General rental price is one-tenth (1/10) of the purchase price per month; allowance for rental will never exceed purchase allowance. Items classified by CMS as Frequent and Substantial Servicing are continuous rentals and excluded from the rent-to-purchase cap.

Threshold — Rent-to-purchase months: 10

Documentation Required

Member-purchased DME reimbursement requirements

Member-submitted reimbursement claims must include vendor receipt with product description and HCPCS code, plus a physician's order containing the appropriate diagnosis code.

Denial Risk

Non-covered sources and items

For BlueCHiP for Medicare, DME obtained from non-contracted providers and certain online purchases are non-covered. Commercial members are not reimbursed for used items or items purchased from private sellers/auction sites.

Billing Rule

Delivery and setup

Delivery and setup are included in the rental or purchase fee and are not separately reimbursed.

Documentation Required

Audit and record retention

BCBSRI may audit services and requires providers to make documentation available; failure to produce documentation may result in denial or retraction of payment.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDurable Medical Equipment (DME) — general guidelines (rent-to-purchase, repair, replacement, maintenance)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2014

Next Review DateN/A

SourceLink

On This Page

E0601	CPAP (continuous positive airway pressure) — referenced as rental example
E0470	Bi-level pressure ventilator, non-invasive — referenced as BIPAP example
E0471	Bi-level pressure ventilator — referenced as BIPAP example

OpenPayer

Durable Medical Equipment (DME) — general guidelines (rent-to-purchase, repair, replacement, maintenance)

Policy Snapshot

Medical Necessity & Coverage Rules

Codes Referenced

Billing, Documentation & Audit Requirements

Key Terms

Numeric Limits & Timeframes

Policy Dates & Changes

Durable Medical Equipment (DME) — general guidelines (rent-to-purchase, repair, replacement, maintenance)

Policy Snapshot

Medical Necessity & Coverage Rules

Codes Referenced

Billing, Documentation & Audit Requirements

Key Terms

Numeric Limits & Timeframes

Also See

Policy Dates & Changes