CurrentBlue Cross Blue Shield - WisconsinPolicy G-06112

Reimbursement for Items under Warranty

Defines the health plan's reimbursement stance for repair or replacement of rented or purchased durable medical equipment, supplies, prosthetics, and orthotics during the manufacturer's warranty period; applies to providers and members covered by the plan (national policy with specific reference to Wisconsin).

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyReimbursement for Items under Warranty

Policy CodePolicy G-06112

Change TypeNo material change

Effective DateSep 11, 2025

Next Review Date

Key ActionProviders must follow authorization and medical necessity guidelines and correct coding rules; claims may be rejected or recouped if billing/coding guidelines are not followed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

warranty — nono reimbursement during warranty

4item types covered

recouprecoupment allowed

partialpartial reimbursement possible

Reimbursement for Items Under Manufacturer Warranty

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Reimbursement criteria for items under warranty

Covered or reimbursed only under the specific conditions below.

No reimbursement for repair or replacement of rented or purchased items during the manufacturer's designated warranty period unless provider, state, federal, or CMS contracts or requirements indicate otherwise.

This warranty reimbursement stance applies to durable medical equipment, supplies, prosthetics, and orthotics; the manufacturer and/or distributor is responsible for repairing the item or providing an acceptable replacement.

Manufacturer/distributor responsibilities include payment of all fees associated with shipment of the defective item and delivery of the repaired item.

If the health plan has reimbursed a provider for repair or replacement during the warranty period, the plan may recoup fees from the manufacturer and/or distributor holding the warranty; providers must supply members with information about the manufacturer's warranty for all items dispensed.

The health plan will consider reimbursement for replacement through another manufacturer only after review and only when both the member and provider deem the manufacturer's replacement unacceptable; design, fitting, training, and related work for the replacement are included in the item reimbursement and are not separately payable.

If the manufacturer offers an acceptable reduced-price replacement but the member or provider selects a full-price alternative, reimbursement is limited to the reduced-price cost; if the manufacturer imposes a pro rata charge for an acceptable replacement, the plan may allow reimbursement for that partial payment subject to approval.

Standard correct coding and billing requirements apply; failure to follow billing/coding guidelines may result in claim rejection, denial, recoupment, or adjustment of reimbursement.

Authorization, Billing and Compliance Requirements

Note

Follow authorization, medical necessity, and correct coding requirements to avoid denials/recoupment

Services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence; follow proper billing and submission practices using industry-standard CPT, HCPCS, and/or revenue codes that are fully supported in the medical record. Failure to follow authorization, coding, or billing guidelines may result in claim rejection, denial, recovery/recoupment of payment, or adjustment of reimbursement.

Obtain any required authorizations and document medical necessity per member state rules.
Bill using appropriate CPT, HCPCS, and/or revenue codes and ensure documentation in the medical record supports billed services.
Be aware that payments may be recovered or adjusted if coding/billing guidelines are not followed.

Referenced Definitions

Definitions (referenced)

Definitions referenceGeneral Reimbursement Policy Definitions as referenced in this policy

Scope of definitionsDefinitions apply to reimbursement rules for repair or replacement of rented or purchased items during the manufacturer’s warranty period

ApplicabilityDefinitions referenced are used throughout the policy to interpret terms related to durable medical equipment, supplies, prosthetics, and orthotics

Primary useServe as the authoritative glossary for terms used in reimbursement determinations and claims processing

LocationListed under the Definitions section of the policy document