Read DME- Tufts Medicare Preferred HMO text version

Durable Medical Equipment Payment Policy

The following payment policy applies to Tufts Medicare Preferred HMO contracted Durable Medical Equipment (DME) providers. Note: Audit and disclaimer information is located at the end of this document.


Tufts Medicare Preferred HMO covers DME when medically necessary up to the member's benefit 1 maximum. Tufts Health Plan will determine whether it is appropriate to purchase or rent equipment for members.

General Benefit Information 2

Member eligibility can be verified electronically and detailed benefit coverage may be verified by contacting Tufts Health Plan Medicare Preferred Provider Relations. Tufts Medicare Preferred HMO follows Medicare coverage guidelines. Tufts Health Plan cannot cover items and services not covered under the CMS-approved Tufts Medicare Preferred HMO benefit plan. Tufts Medicare Preferred HMO's benefit plan currently covers a limited number of non-Medicare covered items as supplemental benefits. Note: Supplemental benefits are subject to change each year.

Member Responsibility

Copayments, deductible and/or coinsurance may apply pursuant to the member's benefit plan document. Tufts Health Plan recommends not billing the member for the coinsurance and/or deductible amount until the claim has processed so that the appropriate member responsibility can be determined. Both the provider's Statement of Account (SOA) and the Electronic Remittance Advice (ERA) will reflect the member's responsibility amount. Providers supplying non-covered items should note that members of Tufts Medicare Preferred HMO can be held liable for non-covered items only if they agree to pay for the items after being informed by the supplying provider that the items are non-covered, and they sign a valid waiver of liability.

Authorization Requirements

Refer to the Authorization Policy for specific referral and authorization requirements. The DME provider is responsible for obtaining the physician's order/prescription for any requested item(s). Prescriptions/orders should include quantity and refill information, as applicable.


CPAP/BiPAP and related supplies require prior authorization through the secure web portal of CareCore National, our sleep benefits manager. The Tufts Health Plan Precertification Department does not handle prior authorization requests for this equipment and related supplies. As a condition of payment, it is the responsibility of the rendering provider to request and obtain prior authorization. If authorization was not obtained or approved, the claim will be denied. If prior authorization is requested but denied by CareCore National, a letter will be sent to the member and provider with appeal rights. Resupplies follow CMS guidelines when compliance criteria are met. DME suppliers will also need to request authorization for supplies and new equipment for existing CPAP and BiPAP machine users.



Authorized medical supplies, respiratory equipment/supplies (excluding CPAP, BiPAP, nebulizers and related supplies), insulin pumps and related diabetic supplies are not applied to a member's benefit maximum. Eligibility is subject to retroactive reporting of disenrollment.

Originated 11/2007, Revised 04/2012 2134207

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Tufts Medicare Preferred HMO DME Payment Policy

The initial visit must be conducted by a Respiratory Therapist or LPN in either the patient's home or an agreed upon location which provides the member and provider a safe and HIPAA-appropriate location for the initial patient orientation. Tufts Health Plan recommends that Durable Medical Equipment (DME) providers use this as an opportunity to educate members on the manufacturer's recommended maintenance/service requirements for CPAP or BiPAP equipment. DME providers or Tufts Health Plan members may initiate requests for repairs or maintenance and service. DME providers must contact members and confirm compliance via objective reporting from the device prior to the end of the third month of use. Compliance is defined as utilization of the prescribed therapy by the patient for an average of four hours a night for 70% of nights during the time of use (defined as the period of time that the member has the therapy equipment). An objective machine-generated report must be obtained by or provided to CareCore National in each of the first 30, 60, and 90 day periods of use in order to extend authorization of services. If a member is noncompliant, it is the DME provider's responsibility to notify the member's physician. The DME provider must request authorization from the member's physician to remove the CPAP or BiPAP equipment from the member's home when determined to be noncompliant or an Against Medical Advice (AMA) form must be signed by the patient These changes will apply to Massachusetts and Rhode Island commercial and Tufts Medicare Preferred HMO plans, with the exception of Tufts Medicare Complement, Tufts Medicare Supplement Plan, commercial PPO plans with the PHCS network, and CareLink. Medical Supplies Required medical/dressing supplies can be obtained by the member from a Tufts Medicare Preferred HMO contracted DME provider with a physician's prescription or, if the member is receiving home health care services, the skilled nurse from the home health care agency can call and order the medical/dressing supplies from a Tufts Medicare Preferred HMO contracted DME provider directly. Some procedures may require prior authorization with the Tufts Health Plan Precertification Department. Refer to the Tufts Medicare Preferred HMO Prior Authorization List for a list of procedures, services and items requiring prior authorization for Tufts Medicare Preferred members. All requests for coverage of DME for Tufts Medicare Preferred HMO members, with the exception of CPAP and BiPAP and related supplies, should be sent the Precertification Department via fax at 617-972-9409. For a complete description of Tufts Health Plan Medicare Preferred HMO's authorization requirements, refer to the Authorization section within the Tufts Medicare Preferred HMO Provider Manual. Oral Enteral Formula Tufts Medicare Preferred HMO members must obtain oral enteral formula through a contracted DME supplier.

Billing Information

· · · · · · Submit the most updated industry standard codes. Submit a modifier, when applicable, with the corresponding CPT and/or HCPCS procedure code(s). For more information regarding modifiers refer to the Modifier Payment Policy Submit multiple same-day services on one line; the number of services/units should reflect all services rendered. Submit unlisted HCPCS procedure code(s) on a paper claim form with supporting documentation detailing what services were provided. Submit oral enteral formula claims with modifier BO (Orally administered nutrition, not by feeding tube).

Originated 11/2007, Revised 04/2012

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Tufts Medicare Preferred DME HMO Payment Policy

Note: Annually and quarterly, HIPAA medical code sets and modifiers undergo revision by CMS, AMA and CCI. Revisions typically include adding, deleting or redefining the description or nomenclature of new HCPCS, CPT procedure and ICD-9 diagnosis codes. As these revisions are made public, Tufts Health Plan Medicare Preferred will update its system to reflect these changes. EDI Claim Submitter Information · Submit claims in HIPAA-compliant 837P format for professional services. Claims billed with nonstandard codes will reject if billed electronically. Paper Claim Submitter Information · Submit claims on a CMS-1500 form for professional services. Claim line(s) billed with non-standard codes will deny. Modifiers Tufts Health Plan Medicare Preferred requires all industry standard modifiers on durable medical equipment, respiratory, medical supplies, orthotics and prosthetic claims. Claims submitted without complete and appropriate modifiers will be denied. This includes modifier EY (No Physician or other Licensed Health Care Provider Order for this Item of Service) and KX (Specific Required Documentation on File) when appropriate per CMS guidelines. Note: Refer to the billing guidelines issued by your Durable Medical Equipment Administrative Contractor (DME MAC) for the most up-to date industry standard guidelines and information regarding modifiers. Oral Enteral Formula · Submit the NDC number for the specific enteral formula product · Submit the product description and the quantity on the claim


Reimbursement Information

Providers are reimbursed according to the Tufts Medicare Preferred HMO network contracted rates regardless of where the service is rendered. Claims are subject to payment edits that are updated at regular intervals and generally based on CMS, Specialty Society Guidelines, and National Correct Coding Initiative (CCI). Oral Enteral Formula Brand name and generic enteral formula will be reimbursed in accordance with the contract. The average wholesale price will be determined by the provider based on the latest published pricing for enteral product in First Data Bank Pricing Guide or in the Red Book. The DME provider is responsible for submitting the AWP rate to the plan for reimbursement. Statement of Account (SOA) The SOA is sent to all providers to provide information on the status of the claim(s) submitted to Tufts Health Plan Medicare Preferred. The SOA indicates status of claims payments, denials and pending claims. If the procedure code(s) submitted is not used in processing, the SOA will reflect the actual procedure code(s) utilized by Tufts Health Plan Medicare Preferred to process the claim. Electronic Remittance Advice (ERA) The HIPAA-compliant 835 ERA is an EDI transaction that providers may request to electronically post paid and denied claims information to their accounts receivable system.


HIPAA medical code sets include HCPCS, CPT Procedure and ICD-9/ICD-10 diagnosis codes.

Originated 11/2007, Revised 04/2012

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Tufts Medicare Preferred DME HMO Payment Policy

Document History

November 2007: Added Tufts Medicare Preferred modifier information. April 2008: Clarified that all requests for coverage of DME for Tufts Medicare Preferred members should be sent the Precertification Department. November 2008: Added information about modifier BO for oral enteral formulas. March 2009: Moved Tufts Medicare Preferred information to its own document. January 2010: Removed references to the Tufts Medicare Preferred PPO document. October 2010: Added information regarding prior authorization of CPAP/BiPAP. March 2011: Reviewed document for clarity; no content changes made. October 2011- Policy reviewed, no content changes, template updates made. April 2012: Template updates made.

Audit and Disclaimer Information

Tufts Health Plan reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in this payment policy. If such an audit determines that your office/facility did not comply with this payment policy, Tufts Health Plan will expect your office/facility to refund all payments related to non-compliance. This policy provides information on Tufts Medicare Preferred HMO claims adjudication processing guidelines. As every claim is unique, the use of this policy is neither a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to member eligibility and benefits on the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, and adherence to plan policies, procedures, and claims editing logic.

Originated 11/2007, Revised 04/2012

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Tufts Medicare Preferred DME HMO Payment Policy


DME- Tufts Medicare Preferred HMO

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