DME for Medicare Advantage
Humana's billing requirements and reimbursement rules for DME provided to Medicare Advantage members, including rental vs purchase, capped rental, oxygen, TENS units, and related billing modifiers.
No material clinical or coverage changes in this revision.
Durable Medical Equipment Coverage & Reimbursement Rules
DME coverage and reimbursement rules
Humana MA reimbursement rules and limitations for DME items
ALL of the following
- Follow applicable CMS guidance except where this policy differs; reimbursement includes delivery and set-up (not separately payable).
[[5]]
- For items that can be rented or purchased, whether rented or purchased is subject to any applicable referral or prior authorization determination.
[[5]]
- Submit appropriate purchase modifier to affect purchase amount: NU = new equipment purchase rate; UE = used equipment purchase rate (typically 75% of new).
[[5]]
- Humana applies Competitive Bidding Program pricing where Original Medicare would; provider contract rental rates apply when DMEPOS Fee Schedule has no rental rate or supplier contract dictates.
[[5]]
ALL of the following
- Submit modifier RR for capped rental items; when RR is submitted amount allowed is the monthly rental rate. Rental allowed for continuous use up to 13 months; after 13 continuous months a capped rental item is considered purchased. Humana may allow purchase rate at any time regardless of RR submission.
[[7]]
- Monthly rental rate calculation (non-power wheelchairs): 10% of purchase rate for first 3 months, then 7.5% thereafter; (power wheelchairs): 15% for first 3 months, then 6% thereafter; monthly rate based on purchase rate in effect for date of service billed.
[[7]]
ALL of the following
- Rental allowed up to 36 continuous months; only one supplier reimbursed per month; gaps >=60 days reset 36-month period; require modifier RR for oxygen rental and one of QA, QB, QE, QF, QG or QR as supported by prescription.
[[10]]
Oxygen modifier effects
- Stationary equipment with QA or QE: amount allowed = 50% of monthly rental rate.
[[10]]
- Stationary equipment with QG or QR: amount allowed = 150% of monthly rental rate.
[[10]]
- Portable equipment with QF or QB: amount allowed = greater of 50% of stationary monthly rental rate or 100% of portable monthly rental rate.
[[10]]
- Oxygen contents are reimbursable except when only a concentrator is supplied the same month, or when a same-month stationary equipment or stationary contents charge exists (portable contents also not separately reimbursable if same-month stationary equipment or contents charge exists). Contents are separately reimbursable when billed same month as maintenance/servicing (maintenance does not include contents).
[[12]]
- Reimbursement for the rental of oxygen equipment includes supplies and accessories; separate reimbursement for supplies/accessories only after 36-month rental period ends.
[[13]]
- Maintenance and servicing (modifier MS) allowed once every six months beginning the later of six months after the 36-month rental period or six months from the manufacturer’s warranty expiration; maintenance for gaseous and liquid equipment is not reimbursable.
[[14]]
ALL of the following
- Acute post-operative pain: allow one-month rental; supplier must submit charge with modifier RR.
[[16]]
- Chronic pain: require appropriate transaction modifier; a two-month rental trial with modifier RR is required to assess suitability and does not count toward the 13-month rental cap or purchase amount. If approved for ongoing use, submit RR for rental monthly rate, or submit purchase modifier for purchase; Humana may allow purchase rate at any time regardless of RR submission.
[[17],[18]]
- Conversion to purchase for TENS: after the two-month trial, the TENS unit is considered purchased in the month the total of all amounts allowed reaches the applicable purchase amount or the rental exceeds 13 months.
[[18],[19]]
DME rental, purchase, repair and replacement criteria
Rules governing when Humana allows rental, purchase, repair or replacement reimbursements and conditions to meet for payment.
ALL of the following
- If a covered DME (including TENS or IRP items) is billed with modifier RR and approved for ongoing use, the amount allowed is the monthly rental rate; Humana reserves the right to allow the purchase rate at any time regardless of RR submission.
[[18],[21]]
- Rental duration: rental allowed up to 13 months continuous use; a two-month rental trial (for e.g., TENS chronic pain) does not count toward the 13-month limit.
[[18]]
- Conversion to purchase: after any excluded trial period, an item is considered purchased in the month when the total of all amounts allowed equals or reaches the applicable purchase amount or when rental exceeds 13 months. For previously rented items, the purchase rate is based on the purchase rate in effect at the time of the first month’s rental (IRP/previous rental rules apply).
[[19],[21]]
ALL of the following
- IRP DME: if billed with RR amount allowed is monthly rental rate; an IRP DME item is considered purchased in the month the total of all amounts allowed equals the applicable purchase amount. Humana determines allowed amount for IRP and TENS IRP items based on the transaction modifier billed.
[[21],[20]]
ALL of the following
- Humana may reimburse replacement of a DME base item, part or accessory after expiration of the reasonable useful lifetime (RUL) if still medically necessary and no longer functional. RUL begins on first date of service when specific base item/part/accessory was individually reimbursed. Required criteria include: maximum allowed units not exceeded; replacement cost (including labor/parts) does not exceed cost of renting or purchasing new base item; not due to intentional damage/neglect/misuse; same member owns base item; not under warranty (documentation of expired or denied warranty required upon request); item not currently being rented.
[[24]]
Replacement before expiration of RUL (one of)
- Member medical needs changed such that a different item is medically necessary. For the first replacement charge in this scenario bill modifier RA with HCPCS code for the replaced base item, part or accessory.
[[26]]
- Item was lost, stolen, or unintentionally damaged beyond repair. For the first replacement charge in this scenario bill modifier RA with HCPCS code for the replaced base item, part or accessory.
[[26]]
- Replacement of a part or accessory in association with a covered repair before RUL when all RB criteria are met (part not an upgrade; necessary to make base item functional; not billed same date as base item; base item not Frequently Serviced or Oxygen Equipment; prior base item charge not denied; base item previously purchased; modifier RR not billed; Box 19 includes base item code and purchase date). When criteria met, bill modifier RB with HCPCS code for replaced part or accessory; allowed at purchase rate.
[[27]]
Modifiers, Codes, and Purchase Conversion Rules
| RR | Rental modifier — submit for capped rental items, oxygen rental, TENS rentals |
| NU | New equipment purchase modifier — allowed at new equipment purchase rate |
| UE | Used equipment purchase modifier — allowed at used equipment purchase rate (typically 75% of new) |
| QA, QB, QE, QF, QG, QR | Oxygen-related modifiers to indicate type/amount of oxygen prescribed; affect monthly rental rate |
| MS | Modifier for maintenance and servicing of certain concentrators and refilling equipment |
| RR | Rental modifier |
| RA | Replacement of a DME, orthotic or prosthetic item |
| RB | Replacement of a part of DME, orthotic or prosthetic item furnished as part of a repair |
| NU | New equipment purchase modifier |
| UE | Used durable medical equipment purchase modifier |
| KH | Initial claim, purchase or first month rental |
| KI | Second or third month rental |
| KJ | Fourth or later month supplied / capped rental months four to fifteen |
Provider Billing Actions & Requirements
Referral / Prior Authorization May Determine Rental vs Purchase
For DME items that can be rented or purchased, whether an item is rented or purchased may be determined by a referral or prior authorization decision. Providers should obtain and document any required referrals or prior authorizations before billing, as that determination can affect whether rental or purchase rates apply.
- Applies to items that can be rented or purchased
Transaction Modifier Required for IRP DME
For items categorized as Inexpensive or Routinely Purchased (IRP) DME, Humana requires an appropriate transaction modifier on the claim. The transaction modifier billed will be used to determine the amount allowed for IRP DME items.
- Transaction modifier required for IRP DME items
Replacement Modifiers and Billing
Replacement billing must follow Medicare-consistent modifier rules. For replacement of a base item, part, or accessory before the expiration of the reasonable useful life (RUL), modifier RA must be billed on the first replacement charge when the replacement is due to changed medical needs or because the item was lost, stolen, or unintentionally damaged beyond repair. For replacement of a part or accessory associated with repair of a base item, modifier RB must be billed with the HCPCS code for the replaced part or accessory when all RB criteria are met (not an upgrade, necessary to make the base item functional, not billed same date as base item, base item not Frequently Serviced or Oxygen Equipment, prior charge for base item not denied, base item previously purchased, RR not billed, and claim includes base item code and purchase date in box 19/electronic equivalent). When requirements are met, replacements allowed at the purchase rate.
- Bill modifier RA on the first replacement charge for a base item, part, or accessory when medical needs changed or item was lost/stolen/damaged beyond repair.
- Bill modifier RB with the HCPCS code for the replaced part or accessory when all RB criteria are met; replacement allowed at the purchase rate.
- Do not bill RB if modifier RR is also billed.
- Include base item code and purchase date on the claim (box 19 or electronic equivalent) when billing RB.
Key Definitions and Modifier Meanings
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