CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Durable Medical Equipment (DME) reimbursement

This payment policy governs reimbursement, rental/purchase rules, repairs, replacements, exclusions, documentation, and claims submission for DME for Neighborhood Health Plan of Rhode Island members across listed lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDurable Medical Equipment (DME) reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must verify member eligibility, coverage, and authorization criteria prior to rendering services and submit home-delivered DME claims through the designated vendor, Integra.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10 monthsstandard rent-to-purchase rental period

60 daysmaximum interruption without restarting rental period

5 yearstypical useful lifetime

Integradesignated DME vendor

Definitions

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Coverage Criteria and Medical Necessity

DME coverage criteria

Covered when ALL of the following medical necessity and program rules are met:

ALL of the following

Services must be medically necessary according to Neighborhood and may be evaluated using: National Coverage Determination (NCD), Local Coverage Determination (LCD), Rhode Island EOHHS recommendations, industry-accepted criteria such as InterQual, and Neighborhood Clinical Medical Policies (CMP).
Provider must verify member eligibility, coverage and authorization prior to rendering services.
Neighborhood may request medical records to support billed services; documentation must meet CMS standards.

ALL of the following

Standard rental period is ten (10) continuous months; monthly rental price is one-tenth (1/10) of the purchase price and Neighborhood's rental allowance will not exceed the purchase allowance.
Items CMS designates as 'Frequent Service' (continuous rental) are excluded from the rent-to-purchase cap and remain continuous rentals.

ALL of the following

Interruptions under sixty (60) consecutive days do not restart the 10-month rental period.
Interruptions over sixty (60) days require a new physician order, documentation of medical necessity, and an explanation of the interruption to initiate a new rental period.
Changing suppliers during a 10-month rental does not initiate a new rental period; the supplier furnishing the item in the 10th month is responsible for supply and maintenance after the rental period.

ALL of the following

Replacement is covered when any of the following apply: change in the member's medical condition requiring a new item; equipment is ordered by a physician; equipment no longer meets functional needs due to growth or significant weight change; manufacturer no longer provides needed support; or cost to repair is comparable to replacement.
Neighborhood follows CMS guidance that the reasonable useful lifetime of rental equipment is typically five (5) years.

ALL of the following

Delivery and set-up are included in the rental or purchase fee and are not separately reimbursed.
Repairs or replacements covered by the manufacturer under warranty are the manufacturer's responsibility and coordinated by the DME provider.
Maintenance (routine periodic servicing such as testing, cleaning, regulating, checking) is not covered.
Deluxe/enhanced items, convenience items, duplicate items for multiple locations, and items primarily to assist a caregiver are not covered.
Purchase, repair, or replacement for items lost, stolen, or destroyed due to member abuse are not covered unless appropriate documentation (explanation, continuing medical necessity, police/fire/insurance report if applicable) is provided.

Coding, Pricing and Rental Rules

DME coding referencemixed

Refer to Neighborhood's DME code guide for covered HCPCS/CPT/ICD-10 codes and frequency/quantity limits.

Rental pricing threshold

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

Rental allowance capNeighborhood's allowance for a rental DME item will never exceed the allowance for a DME purchase item (rental allowance will not exceed purchase allowance).

Standard rental periodStandard rent-to-purchase rental period is ten (10) continuous months; monthly rentals beyond ten consecutive months are non-billable.

Continuous rental exceptionItems CMS classifies as Frequent Service Items are continuous rentals and are excluded from the rent-to-purchase cap.

Provider Responsibilities and Claims Routing

Prior Authorization

Prior verification and vendor claim routing

Providers must verify member eligibility, coverage, and any required authorizations prior to rendering DME services. Claims for DME items delivered to a member's home must be submitted through Neighborhood's designated DME vendor, Integra.

Verify medical necessity using NCDs, LCDs, EOHHS recommendations, Interqual, or Neighborhood Clinical Medical Policies as applicable before providing service.
Submit claims for home-delivered DME through Integra per Neighborhood's claim submission process.
Ensure coding follows CPT, ICD-10-CM, and HCPCS Level II standards when submitting claims.