CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Durable Medical Equipment (DME) Payment Policy

Defines Neighborhood Health Plan of Rhode Island's reimbursement rules, rental-to-purchase, repair/replacement, coverage limitations, exclusions, documentation, and claim submission requirements for DME across Medicaid (excl. EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDurable Medical Equipment (DME) Payment Policy

Policy CodePolicy N/A

Change TypeClarified & Format revised

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and prior authorization requirements before providing DME; submit home-delivered DME claims through Integra.

SourceLink

POLICY UPDATE CHANGES

Added language to interruption of rental period.

Format changed from coding grid to FQLI Grid.

10 monthsstandard DME rental-to-purchase period

60 daysmax interruption without restart

5 yearsuseful lifetime (typical)

Integradesignated claims manager

Coverage Criteria and Rules

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Coverage criteria and rules

Coverage is provided when items are physician-ordered, medically necessary, and supported by documentation; Neighborhood may apply NCD/LCD, InterQual, EOHHS, and Clinical Medical Policies to determine medical necessity.

Item must be physician ordered and medically necessary; Neighborhood may reference National Coverage Determination (NCD), Local Coverage Determination (LCD), InterQual, Rhode Island EOHHS recommendations, and Clinical Medical Policies (CMP).

Provider must verify member eligibility, coverage, and authorization prior to rendering services; documentation in the medical record must support the services billed and the medical necessity per CMS standards.

Repairs are covered when the original equipment was physician-ordered and continues to be medically necessary, or when repair is needed to make the equipment serviceable; rental is covered while a covered DME item is being repaired unless the defective item is under manufacturer warranty.

Replacement is covered when ordered by a physician and one of the following applies: change in the member's medical condition; member growth or significant weight change causing functional needs to change; repair cost is comparable to replacement; or manufacturer no longer supports required upgrades. Neighborhood follows CMS guidance that reasonable useful lifetime for rental equipment is typically 5 years.

Rental-to-purchase and interruption rules: standard rental is 10 continuous months with monthly rental priced at 1/10 of purchase price; interruptions up to 60 consecutive days do not restart the rental period; interruptions greater than 60 days require a new prescription, new medical necessity documentation, and reason for interruption to begin a new rental period.

Change of supplier during an active 10-month rental does not initiate a new rental period; supplier in the 10th month is responsible for the equipment and post-10-month servicing.

Exclusions (not covered): Delivery/setup, routine maintenance, manufacturer-warrantied repairs, maintenance (routine periodic servicing), deluxe/enhanced items, items primarily for convenience, duplicate items for multiple locations, items mainly to assist a caregiver, items resulting from member abuse, and purchase/repair/replacement of stolen or destroyed items except with supporting documentation (medical necessity, explanation, and police/fire/insurance report if applicable).

Claims and coding requirements: claims for home-delivered DME must be submitted through Neighborhood's designated DME vendor (Integra); coding must follow CPT, ICD-10-CM, and HCPCS Level II standards. Inclusion of a code in the policy does not guarantee coverage.

Member financial responsibility: Commercial members may be subject to coinsurance, copays, and deductibles according to their plan selection.

Covered Codes and Pricing Rules

Covered DME codes (refer to external guide)mixed

Reference list of covered DME HCPCS/CPT/ICD-10 codes available in the DME Guide for Frequency, Quantity Limits, and Prior Authorization Requirements.

Coding standards notemixed

CPT/ICD-10/HCPCS

Coding must meet standards defined by the CPT codebook, ICD-10-CM, and HCPCS Level II.

Rental Monthly Pricing Cap

Monthly rental pricingRental is priced at one-tenth (1/10) of the purchase price per month.

Rent-to-purchase periodStandard rental period is ten (10) continuous months; after 10 months the item is considered paid up to the purchase price.

Post-10 month billingCharges for monthly rentals beyond ten consecutive months are non-billable.

Continuous rental exceptionItems classified by CMS as Frequently Serviced Items are continuous rentals, priced at the rental allowance and excluded from the 10-month cap.

Balance for ineffective deviceIf a device is proven ineffective before the end of the 10-month rental and member qualifies for an upgraded device, the remaining balance of the original rental period will be used.

Prior Authorization, Eligibility & Claims Routing

Prior Authorization

Prior Authorization Required

Prior authorization and eligibility verification — Providers must verify member eligibility, benefits, and any prior authorization requirements before rendering services. All services must be medically necessary to qualify for reimbursement. Neighborhood may refer to National Coverage Determinations (NCD), Local Coverage Determinations (LCD), industry-accepted criteria (e.g., InterQual), Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies when determining medical necessity. Providers should consult Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies for details. For questions, contact Provider Services at 1-800-963-1001.

Verify eligibility and coverage prior to service
Confirm and obtain any required prior authorization per Neighborhood's plan-specific processes
Medical necessity will be evaluated using NCDs, LCDs, InterQual, EOHHS recommendations, and CMPs

Billing Rule

DME Claims Submission Routing

Claims for durable medical equipment (DME) delivered to a member's home must be submitted through Neighborhood's designated DME vendor, Integra. Any claims billed by a DME supplier directly to Neighborhood will deny; suppliers must route home-delivered DME claims to Integra. Billable services remain subject to contractual agreements and timely filing requirements. Coding must comply with CPT, ICD-10-CM, and HCPCS Level II standards.

All home-delivered DME claims must be submitted via Integra
Direct claims from DME suppliers to Neighborhood will deny
Submit complete claims within contractual timely-filing limits
Use correct CPT, ICD-10-CM, and HCPCS coding standards

Definitions

Durable Medical Equipment (DME) — Definition and Scope

Definition of DMEDurable Medical Equipment (DME): physician-ordered equipment that withstands repeated use, serves a medical purpose, is generally not useful absent illness or injury, and is appropriate for home use.

Includes related itemsDME includes the supplies necessary for effective use of the equipment, as well as enteral and parenteral supplies, and prosthetics and orthotics.

Clinical purposeDME provides therapeutic benefit based on the patient’s medical condition(s), may facilitate treatment or rehabilitation, and helps restore or improve function.