Point32Health wants to offer our provider network some reminders and clarifying information related to durable medical equipment (DME) services for Tufts Health Together members.
DME service limits
For members of our Tufts Health Together plan, Point32Health follows MassHealth guidance concerning DME items and services — which comprise a broad range of supplies, including oxygen, orthotics, prosthetics, and medical supplies.
MassHealth has defined service limits for DME, which outline how many items may be billed per day and/or month for certain codes. Please be aware that effective for dates of service beginning Aug. 1, 2024, DME services billed in excess of the specified service limits documented by MassHealth may be denied for Tufts Health Together members.
Providers are encouraged to refer to MassHealth’s Payment and Coverage Guideline Tools for information about those service limits. There you can also find service descriptions, applicable modifiers, place-of-service codes, prior authorization requirements, pricing and markup information, and more — and we will be working over the next several months to better manage our application of these requirements, which may result in updates to coding and reimbursement platforms for Tufts Health Together members in an effort to more strongly enforce MassHealth regulations.
Capped rental items
As a reminder, claims for capped rental DME items that are billed without the appropriate capped rental modifier will be denied. Any capped rentals billed in excess of 13 months will also be denied, as they are only considered payable in accordance with the capped rental program for a maximum of 13 months and anything beyond that is outside the scope of the rental period.
For more information, please refer to Point32Health’s updated Durable Medical Equipment and Medical Supplies Payment Policy for Tufts Health Plan products.
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