CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Durable Medical Equipment (DME) reimbursement

Defines Neighborhood Health Plan of Rhode Island's reimbursement, rental, repair, replacement, coverage limits, exclusions, claims submission, and documentation requirements for Durable Medical Equipment across applicable lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDurable Medical Equipment (DME) reimbursement

Policy CodePolicy N/A

Change TypeClarified

Effective DateN/A

Next Review DateN/A

Key ActionVerify eligibility, coverage and prior authorization criteria before rendering services.

SourceLink

POLICY UPDATE CHANGES

Added language to interruption of rental period.

10 monthsstandard DME rent-to-purchase period

60 daysmax interruption without restart

5 yearsuseful lifetime

Integradesignated claims manager

Durable Medical Equipment Coverage Criteria

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DME coverage criteria

Covered when ALL of the following requirements and item-specific rules are met:

ALL of the following

All services must be medically necessary to qualify for reimbursement.
Neighborhood may use NCD, LCD, InterQual, EOHHS recommendations, and Clinical Medical Policies to determine medical necessity.
Provider must verify eligibility, coverage and authorization criteria prior to rendering services.

ALL of the following

Standard rental period is ten (10) continuous months; monthly rental is priced at one‑tenth (1/10) of the purchase price per month; rental charges beyond ten consecutive months are non‑billable unless CMS designates item as rental‑only.
Temporary interruptions of a rental period up to 60 days do not start a new rental period; interruptions greater than 60 days require a new prescription, medical necessity documentation and reason for interruption to start a new 10‑month rental period.

ALL of the following

A change to another DME supplier during a 10‑month rental period will not initiate a new 10‑month rental period.
The supplier providing the item in the 10th month is responsible for the equipment and for post‑10‑month maintenance/arrangements.

ALL of the following

Repair is covered when the original equipment was ordered by a physician and the equipment remains medically necessary.
Repair is covered when it is medically necessary to make the equipment serviceable.
Rental is covered while a covered DME item is being repaired, unless the defective item is still under manufacturer warranty.

ALL of the following

ALL of the following
- ONE of: New item required due to change in member's medical condition
- ONE of: Equipment no longer meets functional needs due to physical changes (eg, skeletal growth or significant weight change)
- ONE of: Cost to repair is comparable to replacement
- ONE of: An upgrade is required and the manufacturer no longer provides needed support for the item
Reasonable useful lifetime for rental equipment is typically 5 years (per CMS).

ALL of the following

Delivery and set up of equipment are included in the rental or purchase fee and are not separately reimbursed.
Repairs and supplies for rental equipment during the rental period are included in the rental allowance (exception: CPAP/BiPAP supplies).
Repair or replacement covered by the manufacturer under warranty is the manufacturer's responsibility and coordinated by the DME provider.
Routine maintenance (testing, cleaning, regulating, checking) is not covered.
NOT covered when: Items resulting from member abuse, theft, or destruction are not covered unless documentation is provided (explanation of continuing medical necessity, explanation that item was stolen/destroyed, and police/fire/insurance report if applicable).

ALL of the following

Neighborhood may request medical records to support billed services; documentation must support billed services and medical necessity and follow CMS documentation standards.
Integra manages DME claims for home‑delivered items; claims billed directly by suppliers to Neighborhood will deny. Coding must follow CPT, ICD‑10‑CM, and HCPCS standards.

Provider Responsibilities and Billing Requirements

Prior Authorization

Prior authorization and eligibility verification — verify eligibility, coverage and prior auth before rendering services

Verify eligibility, coverage, and prior authorization before rendering services. All services must be medically necessary to qualify for reimbursement. Neighborhood may use NCDs, LCDs, InterQual, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies to determine medical necessity. Providers are responsible for verifying eligibility, coverage and authorization criteria prior to rendering services. For plan-specific prior authorization guidance see Neighborhood's Prior Authorization Reference page and Clinical Medical Policies. Contact Provider Services at 1-800-963-1001 with questions.

Documentation Required

Documentation on request — Neighborhood may request medical records to support billed services and medical necessity

Neighborhood reserves the right to request medical records for any billed service. Documentation in the medical record must support the service(s) billed and the medical necessity of the service(s). Neighborhood follows CMS standards for proper documentation requirements. Respond promptly to any documentation requests to avoid payment delays or denials.

Billing Rule

Billing rules for rentals — follow CMS rent-to-purchase guidelines including rental pricing and supplier change rules

Follow CMS rent‑to‑purchase guidelines for DME rentals. Unless CMS designates an item as rental‑only, the rent‑to‑purchase rules below apply. Items classified by CMS as Frequently Serviced Items are continuous rentals and excluded from the 10‑month cap. Neighborhood's rental allowance will not exceed the purchase price allowance.

DME rentals billed monthly for up to ten (10) continuous months; after ten consecutive months the item is considered paid in full and further monthly rental charges are non‑billable.
Monthly rental price = one‑tenth (1/10) of the purchase price per month; Neighborhood's allowance for a rental will never exceed the purchase price allowance.
Continuous rentals (per CMS payment category) are priced at the rental allowance and are excluded from the 10‑month rent‑to‑purchase cap.

Billing Rule

Change in suppliers during rental period — supplier responsibility and rental continuity

A change of supplier during an active 10‑month rental period does NOT start a new rental period. The new supplier may bill for the remaining months in the original rental period. The supplier providing the item in the 10th rental month is responsible for supplying the equipment and for maintenance and servicing after the 10‑month period.

Definitions

Durable Medical Equipment (DME) definition

Order requirementDurable Medical Equipment (DME) must be physician ordered.

Therapeutic purposeProvides therapeutic benefit to a patient based on their medical condition(s) and/or illness(es).

Durability and useAble to withstand repeated use, primarily used to serve a medical purpose, generally not useful absent illness, and appropriate for home use.

Included itemsIncludes the supplies necessary for effective use, Enteral and Parenteral Supplies, and Prosthetics and Orthotics.

Rent-to-purchase definition

Monthly rental calculationMonthly rental equals one-tenth (1/10) of the purchase price.

Purchase at month 11After ten (10) continuous months the rental is considered paid up to the purchase price (i.e., equipment is treated as purchased).

Continuous rental exceptionsItems classified by CMS as Frequently Serviced Items are continuous rentals and excluded from the rent-to-purchase cap.

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

OpenPayer

Durable Medical Equipment (DME) reimbursement

Durable Medical Equipment Coverage Criteria

Codes, Pricing, and Coding Rules

Provider Responsibilities and Billing Requirements

Definitions

Document Revision History