Point32Health is assessing our coding and reimbursement platforms and making updates where necessary to better manage coding related to durable medical equipment (DME) and the application of regulatory requirements.
This work will be implemented through a phased approached over the next several months, and will involve updating configuration and payment policies to more actively apply rules pertaining to:
- proper coding
- the use of appropriate modifiers
- place of service requirements
- adherence to regulatory requirements from governing bodies such as state Medicaid agencies and the Centers for Medicare and Medicaid Services (CMS), as applicable depending on the member’s product
- DME rent-to-purchase rules and associated coding and modifier usage
Reminder: orders/prescriptions for DME supplies
As you may be aware, for some DME items, members may be required to obtain a prescription or order from a physician. The reordering of supplies and accessories is based upon actual patient usage. DME suppliers may not automatically ship supplies to Point32Health members as refills of the original order/prescription. The DME supplier must contact the member at least 14 days prior to dispensing the refill in order to ensure that the item is still reasonable and necessary. This information should be documented in the member’s medical record prior to filling the order for the DME item.
DME suppliers may not dispense a quantity of supplies exceeding the patient’s expected utilization. The supplier should stay attuned to atypical utilization patterns on behalf of their patients and verify with the ordering physician that any atypical utilization is, in fact, warranted. If a claim is billed and the DME supply exceeds regulatory or policy limits, the claim line will be denied.
For more information, please refer to Point32Health’s Durable Medical Equipment and Medical Supplies Payment Policy for Tufts Health Plan products and Durable Medical Equipment (DME) Payment Policy for Harvard Pilgrim products.
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