CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Durable Medical Equipment (DME) reimbursement

Defines Neighborhood Health Plan of Rhode Island's reimbursement, rental/purchase, repair, replacement, exclusions, claims and documentation requirements for physician-ordered 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 TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must verify eligibility, coverage and prior authorization criteria before rendering services and submit DME home-delivery claims through Integra.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10 monthsstandard rental-to-purchase period for DME

60 daysmax interruption without restarting rental

5 yearstypical useful lifetime (replacement guideline)

Medicaid, Integrity, Commercialapplicable lines of business

Integradesignated DME claims manager

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Limitations

Coverage criteria and limitations

Covered when ALL of the following medical necessity, documentation, and program rules are met. Neighborhood may reference NCDs, LCDs, Interqual, RI EOHHS recommendations, and Clinical Medical Policies in determining necessity.

Applies to Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business as applicable to this policy.

All services must be medically necessary to qualify for reimbursement; Neighborhood may use NCD, LCD, industry accepted criteria (e.g., Interqual), RI EOHHS recommendations, and Clinical Medical Policies to determine medical necessity. Providers must verify eligibility, coverage and authorization prior to rendering services.

ALL of the following

Standard rent-to-purchase: rental priced at one-tenth (1/10) of purchase price per month; after 10 continuous months the item is considered purchased and further rental charges are non-billable.
Continuous rental exceptions: items CMS classifies as frequent service are considered continuous rentals and excluded from the rent-to-purchase cap.
Interruptions up to 60 days do not restart the rental period; interruptions greater than 60 days require a new prescription, documentation of medical necessity, and explanation for the interruption to begin a new 10-month rental period.
Changing suppliers during an active 10-month rental does not start a new rental period; the supplier providing the item in the 10th month is responsible for the item and post-10-month maintenance.

Repair coverage — Covered when ONE of the following is met:

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

Replacement coverage — Replacement is covered when ALL of the following are met:

Equipment is ordered by a physician.
AND one of the following must be true:
- A new item is required due to a change in the member's medical condition.
- Equipment no longer meets functional needs due to physical changes (e.g., skeletal growth or significant weight change).
- Cost to repair the DME is comparable to replacement.
- An upgrade is required and the manufacturer no longer provides needed support for the item.

Exclusions and limitations

Delivery and setup 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.
Purchase, repair, or replacement resulting from member abuse is not covered.
Purchase, repair, or replacement for items stolen or destroyed is not covered except when documentation is provided: explanation of continuing medical necessity, explanation that item was stolen or destroyed, and copy of police/fire/insurance report if applicable.

Claims, coding, and submission requirements

Claims for DME delivered to a member's home must be submitted through Neighborhood's designated DME vendor (Integra).
Coding must follow CPT, ICD-10-CM, and HCPCS standards; the inclusion of a code does not guarantee coverage or reimbursement.
Providers must submit complete claims within timely filing guidelines; payments are subject to contract terms, member eligibility, edits, and audits.

Documentation requirements

Neighborhood reserves the right to request medical records for any service billed; documentation must support the services billed and the medical necessity of those services.
Neighborhood follows CMS standards for proper documentation requirements; providers must maintain records and provide them upon request.

Coding, Pricing and Rental Rules

Referenced code sets and code listmixed

No codes listed

Rental monthly pricing

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

Standard rental-to-purchase periodStandard rental period is ten (10) continuous months; after 10 months item is considered purchased.

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

Rental allowance capNeighborhood's rental allowance for a DME item will never exceed the allowance for the DME purchase price item.

Continuous rentals excluded from capItems identified as continuous rentals (CMS 'Frequent Serviced Items') are priced at the rental allowance and excluded from the rent-to-purchase cap.

Prior Authorization and Claims Submission Responsibilities

Prior Authorization

Verify eligibility, authorization, and submit DME claims through Integra

Providers must verify member eligibility, coverage and any required prior authorization before rendering DME services. Refer to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies for authorization requirements. Claims for DME delivered to a member's home must be submitted through Neighborhood's designated DME vendor, Integra; claims billed directly by a DME supplier to Neighborhood will deny. Submit complete claims within contractual timely filing guidelines and follow CPT, ICD-10-CM, and HCPCS coding standards.

Verify eligibility, coverage and authorization prior to service delivery.
Consult the Prior Authorization Reference page and Clinical Medical Policies for plan-specific rules.
Submit home-delivered DME claims through Integra; direct supplier submissions will deny.
Adhere to contractual timely filing rules and CPT/ICD-10-CM/HCPCS coding standards.

Definitions

Durable Medical Equipment (DME) definition

DefinitionDurable Medical Equipment (DME) is physician‑ordered equipment providing therapeutic benefit that is able to withstand repeated use, primarily used for a medical purpose, generally not useful in the absence of illness or injury, and appropriate for home use.

Includes suppliesDME includes the supplies necessary for the effective use of the equipment, such as enteral and parenteral supplies and prosthetics/orthotics.

Intended useMay be used to facilitate treatment and/or rehabilitation, helping to restore and/or improve function.

Frequent Service Items

Frequent Serviced Items designationItems classified by CMS with a payment category of 'Frequent Serviced Items' are considered continuous rentals.

Exclusion from rent-to-purchase cap