CurrentPremera BluecrossPolicy N/A

Durable Medical Equipment (DME) / Home Medical Equipment (HME) reimbursement

Defines how the Plan identifies, codes, bills and reimburses durable medical equipment, prosthetics, orthotics and related supplies for Premera Blue Cross lines of business; applies to providers submitting DME/HME claims and to member benefit determinations.

Policy Summary

PayerPremera Bluecross

PolicyDurable Medical Equipment (DME) / Home Medical Equipment (HME) reimbursement

Policy CodePolicy N/A

Change TypeModifiers, billing rules and code list updates

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility and benefit limits and ensure appropriate HCPCS modifiers and required documentation are included before submitting DME claims.

SourceLink

POLICY UPDATE CHANGES

Added a subsection addressing unlisted DME code submissions and the need for supporting documentation.

Expanded and clarified definitions for Rental-to-Purchase / Purchased Equipment and for Purchased-Only Equipment; added an Oxygen Rentals Only section and clarified partial-month rental billing.

Updated modifiers guidance: removed modifier LL, clarified use of RA, NU, RR, KR, NR and added finger/toe/eyelid and functional prosthetic modifiers; emphasized that appropriate HCPCS modifier is required or claim will be denied.

Updated embedded code list with multiple code additions and terminations effective across 2023-2024 (e.g., E0183, E2102, E2103, K1033, E0468, E2104, E2298, E0736-8, A7021, E0469, etc.).

10-monthcapped rental period after which equipment is considered owned

Coverage criteria and billing rules

DME coverage criteria and billing rules

Covered when ALL of the following documentation, coding and billing requirements are met:

ALL of the following

Coverage determined by member eligibility, benefit limits and Plan Medical Policy; final payment is subject to claims adjudication edits and fee schedule.
Reimbursement limited to provider scope of practice and applicable fee schedule.
Durable Medical Equipment (DME)/Home Medical Equipment (HME) must be appropriate for home use, reusable, primarily medical in purpose, prescribed by a physician, reasonable and necessary, and not for convenience or implantable.
Rental-to-purchase items are rented up to a capped period of 10 months, after which the equipment is considered owned; rental allowances are deducted from purchase price if purchased prior to cap.
Rental-only equipment (e.g., oxygen equipment, ventilators) is billed as continuous rentals and is not typically purchased.

Coding and modifier requirements

An appropriate HCPCS status modifier is required and must be appended as the primary modifier to any submitted DME procedure code or the claim will be denied.
Functional/prosthetic (K0–K4) modifiers must be appended to lower limb prosthetic claims when applicable or the claim will be denied.

Unlisted codes and supporting documentation

Unlisted DME and miscellaneous supply codes should be used only when no other HCPCS Level II code accurately describes the item.
Every unlisted code requires a narrative description (can be entered in Box 19 or Box 24 on professional claims) and supporting documentation such as an invoice identifying the billed item or the manufacturer's suggested retail price (MSRP); provide documentation when requested.

Rental billing and timing rules

Do not submit future-dated rental claims; submit claims after the rental period ends.
Daily rentals (when billed as daily) require from/through dates that match units billed; claim lines must reflect the actual rental period.
A capped rental period of 10 months applies to rental-to-purchase equipment; a lapse greater than 60 days restarts a new rental period (less than 60 days does not).

Included charges and denial risk

Charges included in the rental (e.g., setup, delivery, contents, accessories, maintenance) are not separately reimbursable during the same rental month and separate billing for items included in the rental may be denied.
Failure to append the appropriate HCPCS modifier or to provide required unlisted-code documentation may result in claim denial.

Operational notes

When submitting an unlisted DME code, include the narrative description on the claim and retain invoice/MSRP to supply upon request; see the Unlisted, NonSpecific and Miscellaneous Procedure Codes Payment Policy for additional guidance.
Providers should verify member eligibility and benefit limits and ensure services meet Plan Medical Policy before submission.

Units of service

When monthly rental modifier (RR) is appended, bill one unit per month; when daily/partial-month rental modifier (KR) is appended, bill one unit per day and include from/through dates.

HCPCS modifiers, rental rules, and coding guidance

Required HCPCS modifiers and common status modifiersHCPCS

RR	Rental (Use the RR modifier to indicate a monthly rental)
KR	Rental item-billing for month (Use to indicate daily rentals) partial
NU	New equipment
NR	New when rented. (Use the NR modifier when DME which was new at the time of rental is subsequently purchased)
RA	Replacement of a DME, orthotic or prosthetic item (added as a secondary modifier after either NU or RR)
UE	Used DME

Functional/prosthetic modifiersModifier

K0-K4

Functional level modifiers (K0–K4) for lower limb prosthetics to define patient ability (K0, K1, K2, K3, K4)

Capped rental duration — key facts

Capped rental period10-month capped rental: equipment may be rented for up to 10 months, after which it is considered owned by the member and no additional rental allowance will apply.

Effect of purchase during rentalIf equipment is purchased before the 10-month cap, prior rental allowances will be deducted from the purchase price to determine final payment.

Change of supplierA change of supplier during the 10-month rental period does not initiate a new 10-month rental period; remaining rental months transfer to the new supplier.

Rental lapse threshold — key facts

Lapse threshold to start new rental>60 days — a lapse in rental greater than 60 days starts a new 10-month rental period.

What providers must do before and when submitting claims

Documentation Required

Pre-claim checks: eligibility, benefits, scope and unlisted-code documentation

Verify member eligibility, benefit limits and that the requested service meets the Plan's Medical Policy and the provider's scope of practice prior to claim submission. Ensure required supporting documentation for unlisted HCPCS codes (narrative description and invoice/MSRP) is available and included as instructed on the claim.

Coverage is determined by member eligibility, benefit limits and application of the Plan's Medical Policy; final payment subject to claims adjudication edits and fee schedule (see policy).
Unlisted HCPCS codes require a narrative description and supporting documentation (invoice or MSRP) as described in the unlisted-code subsection.

Billing Rule

Claim timing rules: no future-dated rentals; include from/through dates and correct units

Do not submit future-dated rental claims; claims must be submitted after the end of the rental period. For daily rentals include matching "from" and "through" dates and bill units that equal the total days rented; for monthly rentals append RR and bill one unit per month.

Key definitions

Durable Medical Equipment (DME)/Home Medical Equipment (HME) — definition

DefinitionDurable Medical Equipment (DME)/Home Medical Equipment (HME): equipment and related supplies appropriate for home use that withstand repeated use, are used primarily for medical purposes, not implantable, prescribed by a physician, reasonable and necessary, and not for convenience.

Scope of applicationApplies to equipment, supplies and services submitted to Premera Blue Cross and affiliated lines of business; reimbursement subject to member eligibility, benefit limits and claims adjudication.

Examples / distinctionsPolicy establishes categories including rental-to-purchase, rental-only, purchase-only and oxygen rental-only to guide coding and reimbursement.

Rental-to-Purchase / Purchased Equipment — definition

DefinitionRental-to-Purchase / Purchased Equipment: equipment rented for a designated 10-month capped period; after 10 months the equipment is considered owned by the member.

Policy Summary

PayerPremera Bluecross

PolicyDurable Medical Equipment (DME) / Home Medical Equipment (HME) reimbursement

Policy CodePolicy N/A

Change TypeModifiers, billing rules and code list updates

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility and benefit limits and ensure appropriate HCPCS modifiers and required documentation are included before submitting DME claims.

SourceLink

On This Page

Rental-Only Equipment — definition

DefinitionRental-Only Equipment: items that are rarely or never purchased and are billed continuously as rentals (examples include oxygen-related equipment and ventilators).

Continuous rental rulesContinuous rentals reflect months rented in the dates of service which must match units billed; future-dated submissions are not accepted.

Oxygen specificsMonthly oxygen rental allowance includes stationary/portable equipment, contents and all accessories; supplies/accessories billed separately in the same month will be denied as included in the monthly allowance.