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, exclusions, claim submission, and documentation rules for durable medical equipment for applicable lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDurable Medical Equipment (DME) reimbursement

Policy CodePolicy N/A

Change TypeAdded interruption of rental period language

Effective DateN/A

Next Review DateN/A

Key ActionProviders must verify eligibility, coverage and authorization criteria prior to rendering services and refer to Neighborhood's Prior Authorization Reference page.

SourceLink

POLICY UPDATE CHANGES

Added language to interruption of rental period.

10 monthsstandard DME rental-to-purchase period

60 daysmax interruption without restarting rental

5 yearstypical useful lifetime (replacement)

Integradesignated DME claims vendor

Coverage and Eligibility Requirements

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Coverage criteria

Covered when ALL of the following are met:

ALL of the following

Service must be medically necessary to qualify for reimbursement (Neighborhood may use NCD, LCD, InterQual, EOHHS recommendations, and Clinical Medical Policies to determine medical necessity).
Providers must verify eligibility, coverage and authorization criteria prior to rendering services; refer to Neighborhood's Prior Authorization Reference and Clinical Medical Policies for plan-specific requirements.
Documentation supports medical necessity and billed services; Neighborhood may request medical records and follows CMS documentation standards.
Medical record must support billed services and the medical necessity of those services.

ALL of the following

Original equipment was ordered by a physician and continues to be medically necessary.
Repair is medically necessary to make the equipment serviceable.
Rental of the DME item will be covered while a covered DME item is being repaired, unless the defective item is still under manufacturer warranty.

ALL of the following

Equipment is ordered by a physician.
ONE of
- New item is required due to a change in the member's medical condition.
- Equipment no longer meets the member's functional needs due to physical changes (eg, skeletal growth or significant weight changes).
- Cost to repair the DME is comparable to replacing it.
- An upgrade is required and the manufacturer no longer provides needed support for the item.

ALL of the following

Neighborhood may apply National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), industry accepted criteria such as InterQual, Rhode Island EOHHS recommendations, and Clinical Medical Policies when determining coverage and medical necessity.

ALL of the following

Provider must verify member eligibility, coverage, and any authorization requirements prior to providing DME services.

Operational note

Contact Provider Services at 1-800-963-1001 for questions related to this policy.

Rental and exclusion rules

Rental rules, permitted interruptions, supplier changes, and exclusions that affect reimbursement:

ALL of the following

Standard rental period is ten (10) continuous months; after ten months the item is considered paid and charges beyond ten consecutive months are non-billable.
Monthly rental priced at one-tenth (1/10) of the purchase price; rental allowance will never exceed the purchase allowance.
Items classified by CMS as Frequent Serviced Items are continuous rentals, priced at the rental allowance, and excluded from the rent-to-purchase cap.
If a device is proven ineffective before the end of the ten-month rental and the member qualifies for an upgraded device, the remaining balance of the original rental period for the ineffective device will be used toward the upgrade.

ALL of the following

Codes, Pricing, and Billing Limits

Coding and code list referencemixed

Refer to Neighborhood's DME Guide for list of covered DME codes; coding must meet CPT, ICD-10-CM, and HCPCS standards.

Monthly rental pricing limit - rent = 1/10 purchase price; rentals beyond ten months non-billable

Monthly rental price ruleMonthly rental priced at 1/10 of the purchase price per month

Rental-to-purchase periodStandard rental period is ten (10) continuous months; after 10 months the item is considered paid

Billing beyond 10 monthsCharges for monthly rentals beyond ten consecutive months are non-billable

Rental allowance capNeighborhood's rental allowance will never exceed the allowance for DME purchase price items

Prior Authorization, Eligibility, and Claims Routing

Prior Authorization

Verify authorization and route home-delivered DME claims through Integra

Verify member eligibility, coverage, and any required authorizations before providing DME; consult Neighborhood's plan-specific Prior Authorization Reference page for authorization requirements. Route home-delivered DME claims through Neighborhood's designated vendor, Integra — claims billed directly by a DME supplier to Neighborhood will deny.

Providers must confirm eligibility, coverage and authorization prior to rendering services.
Refer to Neighborhood's plan-specific Prior Authorization Reference page for details.
Submit home-delivered DME claims via Integra; direct supplier-submitted claims to Neighborhood will deny.

Key Terms

Durable Medical Equipment (DME) — definition of DME

DefinitionDurable Medical Equipment (DME): physician-ordered equipment that withstands repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful in the absence of illness or injury, and is appropriate for use in the home

IncludesIncludes the supplies necessary for effective use of the equipment, such as enteral and parenteral supplies, and prosthetics and orthotics

Clinical purposeProvides therapeutic benefit to a patient based on their medical condition(s) and/or illness(es); may facilitate treatment and/or rehabilitation to restore or improve function

Rent-to-purchase — definition and rule for rent pricing and transition to purchase

Rent-to-purchase pricingRental priced at one-tenth (1/10) of the purchase price per month

Conversion to purchaseAfter ten (10) continuous months of rental the item is considered paid and treated as purchased

Continuous rental exceptionItems classified by CMS as Frequent Service Items are considered continuous rentals, priced at the rental allowance, and excluded from the rent-to-purchase cap

Ineffective device guidanceIf a device is proven ineffective before the end of the ten-month rental period and member qualifies for an upgraded device, the remaining balance of the original rental period for the ineffective device will be used

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDurable Medical Equipment (DME) reimbursement

Policy CodePolicy N/A

Change TypeAdded interruption of rental period language

Effective DateN/A

Next Review DateN/A

Key ActionProviders must verify eligibility, coverage and authorization criteria prior to rendering services and refer to Neighborhood's Prior Authorization Reference page.

SourceLink

On This Page

Temporary interruptions in use may last up to 60 days; interruptions less than or equal to 60 consecutive days do NOT restart the rental period.

If an interruption is greater than 60 consecutive days, a new 10-month rental period can begin only if the physician submits a new prescription, new medical necessity documentation, and a statement detailing the reason for the interruption.

When home use ceases due to facility stay (hospital, SNF, hospice, or HMO) and the interruption continues beyond the end of the current rental month, no additional payment will be made until home use resumes; unreimbursed months of interruption will not count toward the rental month limit and a new date of service is established when use resumes.

ALL of the following

Changing to another DME supplier during a 10-month rental period will not initiate a new 10-month rental period, regardless of any lapse in service between suppliers.
A new supplier may bill for the remaining rental months (example: member changes supplier after month 8, new supplier may bill months 9 and 10).
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.

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 manufacturer warranty is the manufacturer's responsibility and coordinated by the DME provider.
Maintenance (routine periodic servicing) is not covered.
Excluded unless documented
- Purchase, repair, or replacement due to member abuse is excluded.
- Purchase, repair, or replacement of stolen or destroyed items is excluded unless documentation (continuing medical necessity, explanation of theft/destruction, and police/fire/insurance report if applicable) is provided.
Deluxe or enhanced DME items are not covered.
DME items and medical supplies primarily for member convenience are not covered (eg, duplicate items for multiple locations; items primarily to assist a caregiver).

Operational note

Neighborhood's designated DME vendor, Integra, manages claim submissions for DME delivered to a member's home; claims billed directly by a supplier may deny—refer to vendor/claim routing requirements.