Durable medical equipment (DME)
Durable medical equipment (DME) is any reusable object or device that provides therapeutic benefits to a patient in the home. DME is used to serve a medical purpose. It is not useful to a person in the absence of illness, disability, or injury, and must be ordered or prescribed by a physician.
Not all DME and prosthetic or orthotic items are covered. For benefit information, see the Durable Medical Equipment policy 91110, Member Inquiry tool or call the Provider Helpline.
- Durable Medical Equipment- 91110
Not all DME and P&O items are covered. For benefit information, see the medical policy above, use the Member Inquiry tool, or call the Provider Helpline.
You must get authorization to prescribe the purchase of any DME item of more than $1,000 (more than $500 for members of Priority Health Medicaid plans).
When a member's pO2 is 55 mmHg or less, he or she qualifies for oxygen and oxygen equipment without prior authorization. Priority Health may audit bi-annually to ensure compliance.
To request authorization for durable medical equipment:
- In-network providers: Use the Auth Request tool to get to Clear Coverage™
- Out-of-network providers: Complete a DME Prior Authorization form and then fax it to Priority Health
Pressure-reduction surfaces and devices
As of Jan. 1, 2018, Priority Health requires a prior authorization for mattress pads or other pressure-reduction surface/device codes E0181, E0182, E0183, E0184, E0185, E0186, E0187, E0196, and E0198 when the purchase price exceeds the $1,000 DME purchase limit ($500 for Medicaid).
Previously, these items were subject to capped rental rules. They may now be purchased outright.
Medicare DME authorizations
Non-covered DME items: Under Part C rules, members must receive a Notice of Denial of Medical Coverage (CMS-10003) from Priority Health OR be notified that the item is excluded by their Evidence of Coverage document before receiving the item or the claim will go to provider liability. Learn more about Medicare non-coverage.
Retroactive requests for authorization: Under Part C rules, these are not allowed. Instead, you must make a payment request when you could not request authorization in advance. How to submit a payment request
DME rental caps
- Ventilator rentals are never capped.
- DME rental is limited to 10 months for most plans.
- Medicare DME rentals are capped at 13 months.
- Medicare oxygen equipment rental is capped at 36 months. See more below.
DME rental agreements, Priority Health Medicare Advantage
For reference, see Chapter 20 of the Medicare Claims Processing Manual, Chapter 20.
Note: Section 10.3, "Beneficiaries Previously Enrolled in Managed Care Who Return to Traditional Fee for Service (FFS)", does not apply to Priority Health Medicare Advantage plan members.
Medicare plan members with no current rental agreement
DME supplier may create a new rental agreement.
New to Priority Health Medicare with a current rental agreement
If a member has an existing rental agreement with the supplier under another company's Medicare Advantage plan, the DME supplier must continue that rental agreement until the capped rental is reached or the member has completed the rent-to-own number of months.
Medicare oxygen and oxygen equipment rental
- Priority Health Medicare follows Medicare rules.
- Oxygen equipment rental is limited to 36 months, at which point Priority Health Medicare will cover maintenance and repair as allowed by Medicare.
- Providers are responsible for tracking rental and should not submit bills for any month beyond 36.
DME dispensed in provider office
- Durable medical equipment (DME) and prosthetics/orthotics (P&O) items dispensed in the provider's office must be billed using the appropriate HCPCS code and modifier (NU and RR: see "Accepted modifiers" section below).
- Coverage is available for standard orthotic/support devices only.
- For Priority Health Medicare Advantage plan members, follow CMS billing rules.
DME obtained from DME provider
A prescription is required for all DME and P&O when items are obtained from licensed DME providers.
Miscellaneous/unlisted DME codes
Do not use code 99070, supplies & materials, when an item, device or piece of equipment is not represented by a specific HCPCS code. Instead, use unlisted codes from the following categories:
- A9999, Miscellaneous DME supply or accessory, not otherwise specified
- E1399, Durable medical equipment, miscellaneous
When billing with one of these codes, notes and invoice must accompany the claim. The notes may consist of a notation of the item in box 19 on the claim or may be an invoice or note describing the item, brand, model, quantity, size, etc.
Items billed under a miscellaneous code will not be paid if a more specific code is available.
Accepted DME modifiers
For Priority Health Medicare Advantage members
Follow the modifier rules in Chapter 14 of the NGS Supplier Manual for Jurisdiction B (enter "DME modifiers" in Search).
For members of all other plans
- NU = New
- RR = Rental
Use this guide to determine if a HCPCS code requires a modifier.
- A codes – Modifiers are required
- B codes – Modifiers are not required
- E codes – NU and RR can be used
- J codes – Modifiers are not required
- K codes – NU and RR can be used
- L codes – NU only
- Q codes – Modifiers are not required
- S codes – Modifiers are not required
- T codes – NU only