CurrentUnitedHealthcarePolicy 2025R9012A

UnitedHealthcare Medicare Advantage Reimbursement Policy — CMS 1500 DME/Prosthetics/Orthotics

Governs UnitedHealthcare Medicare Advantage reimbursement rules for Durable Medical Equipment (DME), prosthetics, orthotics, and related supplies billed on the CMS-1500 form; applies to network physicians, DME/prosthetic/orthotic vendors, and other qualified health care professionals serving Medicare Advantage members.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 DME/Prosthetics/Orthotics Reimbursement Policy

Policy CodePolicy 2025R9012A

Change TypeNon-material revision — Application and History updates

Effective Date

Next Review Date

Key ActionBill monthly rentals as a single claim line with one unit and a single Calendar Month date span; bill multiple months on separate lines.

SourceLink

POLICY UPDATE CHANGES

Application section updated and history section archived entries prior to 6/1/2023.

Medicare AdvantageApplies to

CMS 1500Claim form governed

1/monthMonthly rental rule

6 monthsMaintenance frequency

POS 19,21,22,23,24

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Coverage and Billing Rules

Coverage and billing rules

UnitedHealthcare Medicare Advantage reimburses DME, prosthetics, and orthotics according to CMS-aligned payment categories and specific billing rules for rental vs purchase, maintenance, repairs, place-of-service restrictions, and monthly/daily rental reporting. Covered when the applicable payment and billing requirements below are met:

DME/Prosthetics/Orthotics must be billed consistent with CMS coding and payment categories (Inexpensive/routinely purchased, Frequently Serviced, Certain Customized, Other Prosthetic/Orthotic, Capped Rental, Oxygen).

Claims must indicate whether an item is rented or purchased and must include the appropriate rental (e.g., RR, KH, KI, KJ, KR) or purchase (e.g., NU, UE, NR, KM, KN) modifier to be considered for reimbursement.

Monthly capped rental items (identified by applicable HCPCS code with rental modifier RR and/or KH, KI, KJ, KR) are reimbursed once per Calendar Month to the Same Specialty Physician or Other Qualified Health Care Professional and not to exceed the cap rental period in the provider's contract, after which ownership transfers to the beneficiary.

Daily rental is allowed only for specified codes (example: E0935) and reimbursed on a daily basis consistent with CMS guidelines.

Repairs, replacement parts, and maintenance: payment may be made for repair and replacement of medically required DME (RB for replacement parts; RA for replacement due to loss/irreparable damage) and maintenance/service (MS modifier) is reimbursable once every six months and must be billed on a separate line. Maintenance/service does not apply to Orthotics or Prosthetics.

Reimbursement for certain DME is limited to equipment intended for use in the member's home; suppliers must report the appropriate POS (home POS codes include 01, 04, 09, 12, 13, 14, 16, 33, 54, 55, 56, 65). DME dispensed for use in POS other than the patient's home are not reimbursable.

Purchased items reported on a CMS-1500 by a physician or other qualified health care professional in facility POS (19, 21, 22, 23, 24) are not separately reimbursable when reported with no modifier or with purchase modifiers NU, UE, NR, KM, KN (consistent with facility prospective/global payment rules).

Providers must follow the billing instructions for monthly rental reporting: report each month's rental on a single claim line with one unit and a single Calendar Month date span; multiple months must be billed on separate lines. If two claims from the Same Specialty Physician for the same item show From dates in the same Calendar Month, only one claim will be allowed.

Purchased DME and rental billing criteria

Guidance on when items must be billed as purchased versus rented, and how monthly rental limits and reporting are applied:

Separate reimbursement is not allowed for the purchase of certain DME, orthotics, and prosthetics when reported by a physician or other qualified health care professional on a CMS-1500 claim form in facility POS 19, 21, 22, 23, or 24 if reported with no modifier or with purchase modifiers NU, UE, NR, KM, KN.

Claims must specify rental versus purchase. For purchased equipment, the claim must indicate whether the item is new or used and include the appropriate purchase modifier (e.g., NU, UE, NR) to be considered for reimbursement.

Total reimbursement for a single code (modified with RR and/or NU) from a single vendor is limited to either the purchase price or the maximum number of rental months, whichever is less; rental limits do not apply to oxygen equipment or ventilators.

Monthly rental rules: A rental month is defined as a Calendar Month; monthly capped rental is reimbursed once per Calendar Month and billed as a single claim line with one unit and a single Calendar Month date span. Multiple months must be billed on separate lines. UnitedHealthcare pays the full Calendar Month rental rate and does not prorate for partial-month rentals (KR modifier) except for items listed under Daily Rental.

Modifiers, Codes, and Frequency Rules

Modifiers referencedmixed

RR, KH, KI, KJ, KR	rental modifiers
NU, UE, NR, KM, KN	purchase (new/used) modifiers
RB	replacement parts for beneficiary-owned DME (repairs)
RA	replacement of DME due to loss, irreparable damage or theft
MS	maintenance/service fee modifier
KX	medical necessity expectation modifier (used with second ventilator E0465/E0466)

Purchase modifiers that prevent separate reimbursementModifier | mixedNot Covered

NU	New equipment purchase modifier
UE	Used equipment purchase modifier
NR	Not for resale purchase modifier
KM	Rental purchase modifier (supplier-owned?)
KN	Rental purchase modifier (another variant)

inv-05: Monthly rental limit — reimbursement once per Calendar Month; note capped rental period per provider contract.

Monthly reimbursement ruleReimbursed once per Calendar Month to the Same Specialty Physician or Other Qualified Health Care Professional; applies to monthly capped rental codes with rental modifiers RR and/or KH, KI, KJ, KR.

Cap rental periodPayment not to exceed the cap rental period in the provider's contract; ownership passes to the beneficiary after cap period and supplier must transfer title on first day after cap period.

Provider-level limitationMonthly rental payment is allowed once per Calendar Month to the Same Specialty Physician or Other Qualified Health Care Professional for the same item.

inv-06: Maintenance frequency — maintenance/service reimbursed once every six months.

Maintenance/service frequency

Provider Billing Notes and Requirements

Note

Prior Authorization Note — Medicare Advantage

UnitedHealthcare Medicare Advantage reimbursement policies do not include prior authorization notations. This is informational for providers; check the member's plan or call the number on the member ID card for benefit-specific authorization requirements.

Denial Risk

Denial risk for separate reimbursement in facility POS

UnitedHealthcare Medicare Advantage will not allow separate reimbursement for purchased DME, orthotics, and prosthetics reported by a physician or other qualified health care professional on a CMS-1500 claim form when the service is rendered in a facility Place of Service (POS) where facility prospective payment rates apply. Separate reimbursement is not allowed for services reported in POS 19, 21, 22, 23, or 24 when reported with no modifier or with purchase modifiers NU, UE, NR, KM, or KN.

Affected POS: 19, 21, 22, 23, 24
Disallowed purchase modifiers for separate reimbursement: NU, UE, NR, KM, KN

Defined Terms

inv-11: Durable Medical Equipment (DME) — definition

DefinitionDurable Medical Equipment (DME): Medical equipment which can withstand repeated use; is not disposable; is used to serve a medical purpose; is generally not useful to a person in the absence of sickness or injury; and is appropriate for use in the home.

inv-12: Orthotic — definition

DefinitionOrthotic: An external appliance such as a brace or splint that prevents or assists movement of the spine or limbs; used to support a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body.

inv-13: Prosthetic — definition

DefinitionProsthetic: A device that replaces all or part of an internal body organ or replaces all or part of the function of a permanently inoperative or malfunctioning internal body organ.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 DME/Prosthetics/Orthotics Reimbursement Policy

Policy CodePolicy 2025R9012A

Change TypeNon-material revision — Application and History updates

Effective Date

Next Review Date

Key ActionBill monthly rentals as a single claim line with one unit and a single Calendar Month date span; bill multiple months on separate lines.

SourceLink

On This Page

Maintenance and service reimbursed once every six months to the Same Specialty Physician or Other Qualified Health Care Professional.

Modifier requiredAppropriate HCPCS code must be appended with modifier MS (maintenance/service fee) to identify reimbursable maintenance/service.

Separate line requiredMS modifier must be reported on a separate claim line to be considered for separate reimbursement from rental or purchase of the equipment.

Scope exclusionsMaintenance and service does not apply to Orthotics or Prosthetics under this policy.

inv-07: Rental frequency — rental reimbursed once per Calendar Month; not prorated for partial months.

Monthly rental reimbursementRental reimbursed once per Calendar Month; reported on a single claim line with one unit and a single Calendar Month date span.

No prorationUnitedHealthcare pays a single full Calendar Month rental rate and does not prorate for partial-month use even when modifier KR indicates partial-month rental.

Multiple months billingRental charges for multiple months must be billed on separate claim lines (each line with From/To dates within one Calendar Month).

Billing Rule

Billing rule for monthly rental reporting

Report monthly rentals on a single claim line for each Calendar Month: use one unit and a single From/To date span that covers that calendar month. Do not report multiple months on the same line. If two claims from the same specialty physician or other qualified health care professional show From dates in the same Calendar Month for the same item, only one claim will be allowed. UnitedHealthcare Medicare Advantage reimburses one full Calendar Month rate per provider per month (does not prorate), even when modifier KR (partial month) is used. Follow NUBC/NUCC guidance for From/To date spans; see the policy Monthly Rental examples for formatting multiple months (each line must have a From date in a different month).

Report each month as a separate claim line with one unit and a single Calendar Month date span (From and To).
Do not combine multiple months on one claim line.
Only one claim per provider per item per Calendar Month will be allowed; duplicate From dates in the same month will result in denial of the second claim.
UnitedHealthcare pays a single full Calendar Month rental rate and does not prorate for partial-month use (modifier KR does not change full-month payment).

inv-14: Durable Medical Equipment (DME) — alternate/duplicate definition

Alternate DME wordingDurable Medical Equipment (DME): Medical equipment that can withstand repeated use, is not disposable, serves a medical purpose, is generally not useful in the absence of illness/injury, and is appropriate for use in the home.

inv-15: Orthotic — alternate/duplicate definition

Alternate Orthotic wordingOrthotic: An external appliance such as a brace or splint that prevents or assists movement of the spine or limbs; used to support weak or deformed body parts or restrict/eliminate motion in diseased or injured parts.

inv-16: Prosthetic — alternate/duplicate definition

Alternate Prosthetic wordingProsthetic: A device that replaces all or part of an internal body organ or its function of a permanently inoperative or malfunctioning internal body organ.

inv-17: Rental month (Calendar Month) — definition clarifying 'Calendar Month' rental period for reimbursement

Rental month definitionRental month is defined as a Calendar Month for reimbursement purposes; rentals are paid once per Calendar Month regardless of number of days used.

RationaleUnitedHealthcare uses Calendar Month rather than a 30-day period because billing cycles commonly report rentals with identical calendar-day dates across months (e.g., 1/9, 2/9, 3/9).

Reporting guidanceMonthly rental must be reported with From and To dates within the same Calendar Month; if two claims from the Same Specialty Physician for the same item show From dates in the same month, only one claim will be allowed.