ModifiedIllinois Department of Healthcare and Family ServicesPolicy N/A

DME Fee Schedule Key and Changes

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Defines column headings, billing and prior approval rules, pricing adjustments (including a 2.7% reduction), quantity/day limits, and instructions for items not on the fee schedule for providers billing Durable Medical Equipment to Illinois HFS.

Policy Summary

PayerIllinois Department of Healthcare and Family Services

PolicyDME Fee Schedule Key and Changes

Policy CodePolicy N/A

Change TypeAdditions, revisions, and deletions to HCPCS/L-codes

Effective DateApr 1, 2026

Last ReviewApr 1, 2026

Next Review DateN/A

Key ActionSubmit HFS 1409 Prior Approval Request with medical documentation and an NEC HCPCS code for items not listed on the fee schedule.

SourceLink

POLICY UPDATE CHANGES

Multiple HCPCS and L-codes were added to the fee schedule on various effective dates and numerous codes received price, quantity, or indicator changes; several L-code partial hand codes were deleted effective 04/01/26.

2.7%2.7% statutory reduction

3Partial hand L-codes deleted

~30+Codes added across dates

A4649/E1399/K0108NEC examples for unlisted items

Coverage Rules and Indicators

Coverage indicators

Age-based coverage notes and Medicare billing order determine coverage scope and billing precedence.

Column Note A: Covered for ages 2-99 years.

Column Note B: Covered for ages 5-99 years.

Medicare Covered indicator: If Medicare covers the item (Y), bill Medicare prior to HFS; if Medicare does not cover the item (N), bill HFS directly within 180 days from the date of service. If Medicare coverage is situational, bill Medicare first.

Unlisted items (NEC handling)

Procedure for items not listed on the Illinois HFS fee schedule.

Submit an HFS 1409 Prior Approval Request with medical documentation using a Not Elsewhere Classified (NEC) HCPCS code for items not listed on the fee schedule.

Examples of NEC codes include A4649, E1399, K0108 (this is not an inclusive list).

Operational billing/coverage notes

Operational notices that affect billing, prior approval, and quantity rules.

Continuous Passive Motion Exercise Device (other than knee) was changed to daily rental up to 21 days (see 02/01/22 entry).

Human Breast Milk Processing, Storage, and Distribution was added (see 02/01/22 entry).

The Medicare indicator and Hand Priced indicator were changed for specified items in the 02/01/22 entries (indicators updated from Y to N where noted).

Infusion set/external insulin pump infusion set codes A4230 and A4231 had quantity changes effective 06/01/24.

Groups of codes received price changes (see 01/01/25 price change list).

Chronological DME fee schedule changes

Chronological listing of notable DME fee-schedule changes by effective date (selected entries).

01/01/25: Multiple L- and S-codes had price changes (examples: L5673, L5679, L5681, L5682, L5683, L5810, L5811, L5812, L5816, L5822, L5824, L5828, L5830, L5840, L5970, L5972, L5974, L5976, L5978, L5981, L5982, L5984, L5986, L6582, L6586, L6590, L6694, L6695, L6696, S1040).

04/01/25: L8010 (Breast Prosthesis Mastectomy Sleeve) removed; A4453 (rectal catheter) added; A4459 (manual TAI system) had price/description changes.

10/01/25: A4288 (valve for breast pump, replacement) was added.

01/01/26: Additions include A4295, A4296, A4297, E0468, and E0469 (various catheters and respiratory devices added).

04/01/26: Wheelchair accessory description changes/additions (E1028, E1032–E1034) and deletions of partial-hand L-codes L6000, L6010, L6020.

HCPCS / Fee Schedule Code Details

HCPCS codesHCPCS

HCPCS

Procedure code list; the fee schedule includes a complete list of HCPCS codes; wheelchair codes listed in separate rows.

Not Elsewhere Classified (NEC) examplesHCPCS

A4649	NEC example for items not listed
E1399	NEC example for items not listed
K0108	NEC example for items not listed

Examples of codes added 01/01/22HCPCSCovered

E0958
E0959
K0005
K0020

Examples of codes with price changes effective 01/01/25HCPCSCovered

L6050	Price change noted for effective 01/01/25 group
L0630	Included in 01/01/25 list

Additions/removals effective 04/01/25HCPCS

L8010	Breast Prosthesis Mastectomy Sleeve removed effective 04/01/25
A4453	Rectal Cath W/WO Balloon for Use W/ Any Type TAI Sys, each added effective 04/01/25

01/01/25 price changesHCPCS

L5673	Price change indicated
S1040	Price change indicated

04/01/25 additions/removals/changesHCPCS

A4453	Rectal catheter with or without balloon for use with any type TAI system, each (added)
A4459	Manual TAI system with water reservoir, pump, accessory, without catheter (price/description change)
L8010	Breast prosthesis mastectomy sleeve (removed)

10/01/25 additionsHCPCS

A4288

Valve for breast pump, replacement (added)

01/01/26 additionsHCPCS

A4295	Intermittent urinary catheter; straight tip, hydrophilic coating, each (added)
A4296	Intermittent urinary catheter; coude (curved tip), hydrophilic coating, each (added)
A4297	Intermittent urinary catheter; hydrophilic coating, with insertion supply (added)
E0468	Home ventilator dual function cough stimulator, includes all accessories and supplies (added)
E0469	Lung expansion/airway clearance, high frequency oscillation plus nebulizer device (added)

04/01/26 updates and deletionsHCPCS

E1028	Wheelchair accessory - manual swingaway/retractable/removable mounting hardware, other (description change)
E1032	Wheelchair accessory used with joystick - other (added)
L6000	Partial hand, thumb remaining (deleted)
L6010	Partial hand, little and/or ring finger remaining (deleted)
L6020	Partial hand; no finger remaining (deleted)

inv-15: Max Quantity/Max Days

Max QuantityMaximum quantity HFS will allow within the Max number of days as defined on fee schedule rows.

Max DaysTime frame in which the Max Quantity limit applies; defines the quantity limit time frame.

ApplicabilityLimits are enforced per fee schedule row; providers must follow the Max Quantity within the Max Days for claims submission.

inv-16: Hand Priced indicator

Hand Priced indicator changeThe Hand Priced (H/P) indicator was changed from Y to N for specified codes in the 01/01/22 entry.

DefinitionH/P denotes whether the item is hand-priced on the fee schedule.

DocumentationIndicator changes are noted inline in chronological fee schedule changes; see effective-date entries for affected codes.

inv-17: Medicare indicator

Medicare indicator changeThe Medicare coverage indicator was changed from Y to N for specified items (noted in the 02/01/22 entries).

Billing orderIf Medicare covers an item (Medicare Covered = Y), bill Medicare prior to HFS; if N, bill HFS directly within 180 days.

Situational coverageIf Medicare coverage policy is situational, bill Medicare first as directed in the Medicare Covered definition.

inv-18: Effective dates present

01/01/25Effective date for listed price changes (e.g., L5673, L5679, ... S1040).

04/01/25Effective date for additions/removals/description changes (e.g., L8010 removed; A4453, A4459 added/changed).

10/01/25Effective date for additions (e.g., A4288 added).

01/01/26Effective date for additions (e.g., A4295, A4296, A4297, E0468, E0469 added).

04/01/26Effective date for wheelchair accessory updates and L-code deletions (e.g., E1028-E1034 changes; L6000-L6020 deleted).

Provider Billing, Prior Authorization, and Operational Changes

Prior Authorization

Submit HFS 1409 for Prior Approval and NEC items

Submit an HFS 1409 Prior Approval Request with medical documentation when prior approval is required, and for items not listed on the fee schedule use a Not Elsewhere Classified (NEC) HCPCS code on the HFS 1409 submission (examples: A4649, E1399, K0108).

Use HFS 1409 for prior approval requests and include supporting medical documentation.
For items not on the fee schedule, bill using an NEC code and include the NEC on the HFS 1409 form.

Documentation Required

Prior Approval indicator legend (N/Y/R/B/E)

Follow the fee schedule Prior Approval indicator meanings exactly: N = No PA required; Y = PA required; R = Continuous Rental - PA required; B = Rent to Purchase - PA required; E = Requires PA for Purchase or Modifications (repairs require PA when repair total is $1,500 or more).

N — No prior approval required
Y — Prior approval required
R — Continuous rental; prior approval required
B — Rent to purchase; prior approval required
E — Prior approval required for purchase or modifications; repairs require PA when repair total ≥ $1,500

Billing Rule

Added services and rental rule change

Note the specific service and rental rule changes: Human Breast Milk Processing, Storage, and Distribution was added; Continuous Passive Motion Exercise Device (other than knee) was changed to daily rental up to 21 days.

Human Breast Milk Processing, Storage, and Distribution — added
Continuous Passive Motion Exercise Device, other than knee — changed to daily rental up to 21 days

Billing Rule

Infusion set quantity updates (A4230, A4231)

Adjust billing quantities per the fee schedule changes: A4230 (Infusion Set/External Insulin Pump, Non-Needle Cannula Type) and A4231 (Infusion Set, External Insulin Pump, Needle Type) had quantity changes effective 06/01/24 — bill per the updated max quantity limits shown on the fee schedule.

A4230 — quantity change (see fee schedule row for updated Max Quantity/Max Days)
A4231 — quantity change (see fee schedule row for updated Max Quantity/Max Days)

Billing Rule

Codes with price changes effective 01/01/25

Apply the 01/01/25 price changes to the listed codes when submitting claims; the fee schedule marks these codes with '1 = Price change'.

Affected L-codes include: L5673, L5679, L5681, L5682, L5683, L5810, L5811, L5812, L5816, L5822, L5824, L5828, L5830, L5840, L5970, L5972, L5974, L5976, L5978, L5981, L5982, L5984, L5986, L6582, L6586, L6590, L6694, L6695, L6696
Also affected: S1040 — price change

Billing Rule

Code removals and additions effective 04/01/25

Update billing for additions and removals effective 04/01/25: L8010 (Breast Prosthesis Mastectomy Sleeve) was removed; A4453 (rectal catheter) was added; A4459 (manual TAI system) had a price/description change — bill or stop-billing these codes per the effective date.

L8010 — removed effective 04/01/25
A4453 — added effective 04/01/25 (Rectal catheter for use with any type TAI system)
A4459 — price/description change effective 04/01/25 (Manual TAI system without catheter)

Billing Rule

04/01/26 deletions and wheelchair accessory updates

Prepare for deletions and wheelchair accessory updates effective 04/01/26: wheelchair accessory codes E1028–E1034 have description additions/changes, and partial hand L-codes L6000, L6010, L6020 were deleted — do not bill deleted L-codes after the effective date and use updated E-code descriptions/pricing.

E1028 — wheelchair accessory description change (manual swingaway/retractable/removable mounting hardware, other)
E1032–E1034 — wheelchair accessory codes added/updated (use updated descriptions)
L6000, L6010, L6020 — deleted effective 04/01/26; do not submit claims for these codes after this date

Column and Indicator Definitions

inv-26: HCPCS

HCPCSHCPCS — Procedure code used on the HFS DME Fee Schedule.

ScopeFee schedule includes a complete list of HCPCS procedure codes for DME items.

UseProviders must use HCPCS codes on claims to identify billed DME services and items.

inv-27: A (Note)

A (Note)Covered for ages 2-99 years.

ApplicationUsed in the Note column on the fee schedule to indicate age-based coverage limits.

InterpretationProviders should verify patient age falls within 2–99 years when A is indicated.

inv-28: B (Note)

B (Note)Covered for ages 5-99 years.

ApplicationUsed in the Note column on the fee schedule to indicate age-based coverage limits.

InterpretationProviders should verify patient age falls within 5–99 years when B is indicated.

inv-29: Prior Approval Required

Prior Approval legendN = No PA required; Y = PA required; R = Continuous Rental - PA required; B = Rent to Purchase - PA required; E = Requires PA for Purchase or Modifications. Repairs require prior approval when the repair total is $1500 or more.

MeaningIndicates whether prior approval is required for the item.

ActionSubmit HFS 1409 Prior Approval Request with medical documentation when PA is required, or for items not listed using an NEC code.

inv-30: H/P

H/P (Hand-Priced)Indicates if the item is hand-priced on the fee schedule.

Flag useShown in the H/P column to identify items priced manually rather than by posted fee schedule rates.

ChangesHand-priced indicator changes (e.g., Y to N) are noted in chronological fee schedule change entries.

inv-31: LTC

LTC (Long-Term Care Responsibility)Y = LTC responsibility; N = Not LTC responsibility.

PurposeIndicates whether the Long-Term Care program is financially responsible for the item.

Billing implicationProviders should follow LTC responsibility indicator when determining payer for DME items supplied to LTC beneficiaries.

inv-32: Pair

Pair column'*' = billed as a pair with quantity of 1; '2' = HFS pays two when medically necessary with prior approval. Providers should bill one line with quantity 1 for items marked '*' or '2'.

Billing ruleIf '*' appears, bill one line with quantity 1 representing the pair; if '2' appears, bill one line with quantity 1 and obtain PA where two units are medically necessary.

InterpretationClarifies left/right pair billing behavior to avoid duplicate or incorrect billing.

inv-33: Medicare Covered

Medicare Covered indicatorY = Bill Medicare prior to HFS; N = Not covered by Medicare; bill HFS directly within 180 days from the date of service. If Medicare coverage policy is situational, bill Medicare first.

Billing sequenceWhen Medicare coverage applies (Y), providers must submit claims to Medicare before billing HFS.

TimingFor items not covered by Medicare (N), providers may bill HFS within 180 days of service.

inv-34: 2.7% Reduced Purchase Price

2.7% Reduced Purchase PricePublic Act 097-0689 requires a 2.7% reduction to reimbursement rates; posted maximum allowable purchase prices are reduced by 2.7% unless marked 'NR'.

ScopeApplies to maximum allowable purchase prices for most DME items on the fee schedule.

ExceptionItems marked 'NR' in the Note column are not subject to the 2.7% reduction.

inv-35: 2.7% Reduced Rent Price

2.7% Reduced Rent PriceMaximum allowable rental price after the 2.7% statutory reduction.

ApplicationRent prices listed on the fee schedule reflect the 2.7% reduction unless otherwise noted.

Relation to purchase priceRental rate reductions are applied similarly to purchase price reductions under the statutory requirement.

inv-36: Hand Priced indicator (definition instance)

Hand Priced indicator (flag)Denotes presence of a hand-priced flag (H/P) in the schedule; entries note when the indicator was changed (for example, changed from Y to N in the 01/01/22 listing).

Column placementDisplayed in the H/P column of the fee schedule to identify hand-priced items.

ImplicationHand-priced items may require manual pricing by HFS or special billing instructions.

inv-37: Medicare indicator (definition instance)

Medicare indicator (flag)Denotes the Medicare coverage indicator present in the schedule; this document records instances where the indicator changed from Y to N (e.g., shown in 02/01/22 entries).

FunctionIndicates whether Medicare should be billed prior to HFS (Y) or not (N).

Provider actionFollow billing order as indicated by the Medicare Covered column when submitting claims.

inv-38: 1 = Price change

1 = Price changeShort status label on fee schedule rows indicating a price change occurred for the listed code(s).

UsageAppears inline with chronological effective-date entries to denote price adjustments (see 01/01/25 entry).

ImplicationProviders should reference the effective date when billing at updated prices.

inv-39: removed

removedStatus label indicating the code was deleted from the fee schedule (examples: L6000, L6010, L6020 deleted effective 04/01/26; L8010 removed effective 04/01/25).

ImplicationDeleted codes should not be billed after the effective deletion date; providers must use replacement or alternative codes if available.

ReferenceRemoval entries are noted with the 'removed' status in chronological fee schedule changes.

Policy Summary

PayerIllinois Department of Healthcare and Family Services

PolicyDME Fee Schedule Key and Changes

Policy CodePolicy N/A

Change TypeAdditions, revisions, and deletions to HCPCS/L-codes

Effective DateApr 1, 2026

Last ReviewApr 1, 2026

Next Review DateN/A

Key ActionSubmit HFS 1409 Prior Approval Request with medical documentation and an NEC HCPCS code for items not listed on the fee schedule.

SourceLink

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DME Fee Schedule Key and Changes

Customize your policy alerts

Sign up for all Illinois Department of Healthcare and Family Services policy alerts

Know when Illinois Department of Healthcare and Family Services releases new policies or updates existing guidance.

Monitor payer policy activity

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Coverage Rules and Indicators

Coverage indicators

Age-based coverage notes and Medicare billing order determine coverage scope and billing precedence.

Column Note A: Covered for ages 2-99 years.

Column Note B: Covered for ages 5-99 years.

Unlisted items (NEC handling)

Procedure for items not listed on the Illinois HFS fee schedule.

Submit an HFS 1409 Prior Approval Request with medical documentation using a Not Elsewhere Classified (NEC) HCPCS code for items not listed on the fee schedule.

Examples of NEC codes include A4649, E1399, K0108 (this is not an inclusive list).

Operational billing/coverage notes

Operational notices that affect billing, prior approval, and quantity rules.

Continuous Passive Motion Exercise Device (other than knee) was changed to daily rental up to 21 days (see 02/01/22 entry).

Human Breast Milk Processing, Storage, and Distribution was added (see 02/01/22 entry).

The Medicare indicator and Hand Priced indicator were changed for specified items in the 02/01/22 entries (indicators updated from Y to N where noted).

Infusion set/external insulin pump infusion set codes A4230 and A4231 had quantity changes effective 06/01/24.

Groups of codes received price changes (see 01/01/25 price change list).

Chronological DME fee schedule changes

Chronological listing of notable DME fee-schedule changes by effective date (selected entries).

04/01/25: L8010 (Breast Prosthesis Mastectomy Sleeve) removed; A4453 (rectal catheter) added; A4459 (manual TAI system) had price/description changes.

10/01/25: A4288 (valve for breast pump, replacement) was added.

01/01/26: Additions include A4295, A4296, A4297, E0468, and E0469 (various catheters and respiratory devices added).

04/01/26: Wheelchair accessory description changes/additions (E1028, E1032–E1034) and deletions of partial-hand L-codes L6000, L6010, L6020.

HCPCS / Fee Schedule Code Details

HCPCS codesHCPCS

HCPCS

Procedure code list; the fee schedule includes a complete list of HCPCS codes; wheelchair codes listed in separate rows.

Not Elsewhere Classified (NEC) examplesHCPCS

A4649	NEC example for items not listed
E1399	NEC example for items not listed
K0108	NEC example for items not listed

Examples of codes added 01/01/22HCPCSCovered

E0958
E0959
K0005
K0020

Examples of codes with price changes effective 01/01/25HCPCSCovered

L6050	Price change noted for effective 01/01/25 group
L0630	Included in 01/01/25 list

Additions/removals effective 04/01/25HCPCS

L8010	Breast Prosthesis Mastectomy Sleeve removed effective 04/01/25
A4453	Rectal Cath W/WO Balloon for Use W/ Any Type TAI Sys, each added effective 04/01/25

01/01/25 price changesHCPCS

L5673	Price change indicated
S1040	Price change indicated

04/01/25 additions/removals/changesHCPCS

A4453	Rectal catheter with or without balloon for use with any type TAI system, each (added)
A4459	Manual TAI system with water reservoir, pump, accessory, without catheter (price/description change)
L8010	Breast prosthesis mastectomy sleeve (removed)

10/01/25 additionsHCPCS

A4288

Valve for breast pump, replacement (added)

01/01/26 additionsHCPCS

A4295	Intermittent urinary catheter; straight tip, hydrophilic coating, each (added)
A4296	Intermittent urinary catheter; coude (curved tip), hydrophilic coating, each (added)
A4297	Intermittent urinary catheter; hydrophilic coating, with insertion supply (added)
E0468	Home ventilator dual function cough stimulator, includes all accessories and supplies (added)
E0469	Lung expansion/airway clearance, high frequency oscillation plus nebulizer device (added)

04/01/26 updates and deletionsHCPCS

E1028	Wheelchair accessory - manual swingaway/retractable/removable mounting hardware, other (description change)
E1032	Wheelchair accessory used with joystick - other (added)
L6000	Partial hand, thumb remaining (deleted)
L6010	Partial hand, little and/or ring finger remaining (deleted)
L6020	Partial hand; no finger remaining (deleted)

inv-15: Max Quantity/Max Days

Max QuantityMaximum quantity HFS will allow within the Max number of days as defined on fee schedule rows.

Max DaysTime frame in which the Max Quantity limit applies; defines the quantity limit time frame.

ApplicabilityLimits are enforced per fee schedule row; providers must follow the Max Quantity within the Max Days for claims submission.

inv-16: Hand Priced indicator

Hand Priced indicator changeThe Hand Priced (H/P) indicator was changed from Y to N for specified codes in the 01/01/22 entry.

DefinitionH/P denotes whether the item is hand-priced on the fee schedule.

DocumentationIndicator changes are noted inline in chronological fee schedule changes; see effective-date entries for affected codes.

inv-17: Medicare indicator

Medicare indicator changeThe Medicare coverage indicator was changed from Y to N for specified items (noted in the 02/01/22 entries).

Billing orderIf Medicare covers an item (Medicare Covered = Y), bill Medicare prior to HFS; if N, bill HFS directly within 180 days.

Situational coverageIf Medicare coverage policy is situational, bill Medicare first as directed in the Medicare Covered definition.

inv-18: Effective dates present

01/01/25Effective date for listed price changes (e.g., L5673, L5679, ... S1040).

04/01/25Effective date for additions/removals/description changes (e.g., L8010 removed; A4453, A4459 added/changed).

10/01/25Effective date for additions (e.g., A4288 added).

01/01/26Effective date for additions (e.g., A4295, A4296, A4297, E0468, E0469 added).

04/01/26Effective date for wheelchair accessory updates and L-code deletions (e.g., E1028-E1034 changes; L6000-L6020 deleted).

Provider Billing, Prior Authorization, and Operational Changes

Prior Authorization

Submit HFS 1409 for Prior Approval and NEC items

Use HFS 1409 for prior approval requests and include supporting medical documentation.
For items not on the fee schedule, bill using an NEC code and include the NEC on the HFS 1409 form.

Documentation Required

Prior Approval indicator legend (N/Y/R/B/E)

N — No prior approval required
Y — Prior approval required
R — Continuous rental; prior approval required
B — Rent to purchase; prior approval required
E — Prior approval required for purchase or modifications; repairs require PA when repair total ≥ $1,500

Billing Rule

Added services and rental rule change

Human Breast Milk Processing, Storage, and Distribution — added
Continuous Passive Motion Exercise Device, other than knee — changed to daily rental up to 21 days

Billing Rule

Infusion set quantity updates (A4230, A4231)

A4230 — quantity change (see fee schedule row for updated Max Quantity/Max Days)
A4231 — quantity change (see fee schedule row for updated Max Quantity/Max Days)

Billing Rule

Codes with price changes effective 01/01/25

Apply the 01/01/25 price changes to the listed codes when submitting claims; the fee schedule marks these codes with '1 = Price change'.

Affected L-codes include: L5673, L5679, L5681, L5682, L5683, L5810, L5811, L5812, L5816, L5822, L5824, L5828, L5830, L5840, L5970, L5972, L5974, L5976, L5978, L5981, L5982, L5984, L5986, L6582, L6586, L6590, L6694, L6695, L6696
Also affected: S1040 — price change

Billing Rule

Code removals and additions effective 04/01/25

L8010 — removed effective 04/01/25
A4453 — added effective 04/01/25 (Rectal catheter for use with any type TAI system)
A4459 — price/description change effective 04/01/25 (Manual TAI system without catheter)

Billing Rule

04/01/26 deletions and wheelchair accessory updates

E1028 — wheelchair accessory description change (manual swingaway/retractable/removable mounting hardware, other)
E1032–E1034 — wheelchair accessory codes added/updated (use updated descriptions)
L6000, L6010, L6020 — deleted effective 04/01/26; do not submit claims for these codes after this date

Column and Indicator Definitions

inv-26: HCPCS

HCPCSHCPCS — Procedure code used on the HFS DME Fee Schedule.

ScopeFee schedule includes a complete list of HCPCS procedure codes for DME items.

UseProviders must use HCPCS codes on claims to identify billed DME services and items.

inv-27: A (Note)

A (Note)Covered for ages 2-99 years.

ApplicationUsed in the Note column on the fee schedule to indicate age-based coverage limits.

InterpretationProviders should verify patient age falls within 2–99 years when A is indicated.

inv-28: B (Note)

B (Note)Covered for ages 5-99 years.

ApplicationUsed in the Note column on the fee schedule to indicate age-based coverage limits.

InterpretationProviders should verify patient age falls within 5–99 years when B is indicated.

inv-29: Prior Approval Required

MeaningIndicates whether prior approval is required for the item.

ActionSubmit HFS 1409 Prior Approval Request with medical documentation when PA is required, or for items not listed using an NEC code.

inv-30: H/P

H/P (Hand-Priced)Indicates if the item is hand-priced on the fee schedule.

Flag useShown in the H/P column to identify items priced manually rather than by posted fee schedule rates.

ChangesHand-priced indicator changes (e.g., Y to N) are noted in chronological fee schedule change entries.

inv-31: LTC

LTC (Long-Term Care Responsibility)Y = LTC responsibility; N = Not LTC responsibility.

PurposeIndicates whether the Long-Term Care program is financially responsible for the item.

Billing implicationProviders should follow LTC responsibility indicator when determining payer for DME items supplied to LTC beneficiaries.

inv-32: Pair

Pair column'*' = billed as a pair with quantity of 1; '2' = HFS pays two when medically necessary with prior approval. Providers should bill one line with quantity 1 for items marked '*' or '2'.

Billing ruleIf '*' appears, bill one line with quantity 1 representing the pair; if '2' appears, bill one line with quantity 1 and obtain PA where two units are medically necessary.

InterpretationClarifies left/right pair billing behavior to avoid duplicate or incorrect billing.

inv-33: Medicare Covered

Billing sequenceWhen Medicare coverage applies (Y), providers must submit claims to Medicare before billing HFS.

TimingFor items not covered by Medicare (N), providers may bill HFS within 180 days of service.

inv-34: 2.7% Reduced Purchase Price

2.7% Reduced Purchase PricePublic Act 097-0689 requires a 2.7% reduction to reimbursement rates; posted maximum allowable purchase prices are reduced by 2.7% unless marked 'NR'.

ScopeApplies to maximum allowable purchase prices for most DME items on the fee schedule.

ExceptionItems marked 'NR' in the Note column are not subject to the 2.7% reduction.

inv-35: 2.7% Reduced Rent Price

2.7% Reduced Rent PriceMaximum allowable rental price after the 2.7% statutory reduction.

ApplicationRent prices listed on the fee schedule reflect the 2.7% reduction unless otherwise noted.

Relation to purchase priceRental rate reductions are applied similarly to purchase price reductions under the statutory requirement.

inv-36: Hand Priced indicator (definition instance)

Hand Priced indicator (flag)Denotes presence of a hand-priced flag (H/P) in the schedule; entries note when the indicator was changed (for example, changed from Y to N in the 01/01/22 listing).

Column placementDisplayed in the H/P column of the fee schedule to identify hand-priced items.

ImplicationHand-priced items may require manual pricing by HFS or special billing instructions.

inv-37: Medicare indicator (definition instance)

Medicare indicator (flag)Denotes the Medicare coverage indicator present in the schedule; this document records instances where the indicator changed from Y to N (e.g., shown in 02/01/22 entries).

FunctionIndicates whether Medicare should be billed prior to HFS (Y) or not (N).

Provider actionFollow billing order as indicated by the Medicare Covered column when submitting claims.

inv-38: 1 = Price change

1 = Price changeShort status label on fee schedule rows indicating a price change occurred for the listed code(s).

UsageAppears inline with chronological effective-date entries to denote price adjustments (see 01/01/25 entry).

ImplicationProviders should reference the effective date when billing at updated prices.

inv-39: removed

removedStatus label indicating the code was deleted from the fee schedule (examples: L6000, L6010, L6020 deleted effective 04/01/26; L8010 removed effective 04/01/25).

ImplicationDeleted codes should not be billed after the effective deletion date; providers must use replacement or alternative codes if available.

ReferenceRemoval entries are noted with the 'removed' status in chronological fee schedule changes.