Items identified in the DMEPOS Fee Schedule with a rental and purchase option require prior authorization to determine if the recipient’s needs justify rental or purchase based on the item prescribed, the individual’s anticipated length of need and prognosis (as determined by theprescriber) and cost effectiveness to the DHCFP and NCU.
a. RENTAL
1. In addition to all other requirements and qualifications for specific products, if the DMEPOS Fee Schedule allows a rental option, a device may be rented when:
a. the anticipated length of need (per physician’s/practitioner’s order) is short term (six months or less) and rental would be more cost effective than purchase;
b. a temporary trial period is required for the item according to Medicaid’s
policy;
c. the item is only available as a rental per the DMEPOS Fee Schedule; or d. a temporary rental is needed while a recipient-owned like item is being
repaired.
2. During a rental period, rental rates include all supplies and accessories necessary to render the equipment useable and safe, delivery and set up services, education and training for recipient and family, routine maintenance and servicing (such as testing, cleaning, regulating and checking equipment), repairs, non-routine
maintenance and servicing (such as breaking down sealed components and performing tests which require specialized equipment and skills of a technician), and replacement of items. These services are the responsibility of the owner, the DMEPOS supplier.
3. Throughout any rental period, there must be an active physician’s/practitioner’s order for ongoing use, the prior authorization effective dates are still applicable, and there is a continued medical need for the item. The DMEPOS supplier must contact the recipient or their representative within five business days prior to each billing cycle to verify the rented item is still medically necessary, in working condition, and being used by the recipient (contact does not include system
generated correspondence). Verification must be documented and maintained in the DMEPOS supplier’s records and be accessible for audits.
4. Rent-to-Purchase Option:
a. The DHCFP allows rental of certain DMEPOS items up to the provider’s Usual and Customary Charge (UCC) for purchase, or the maximum Medicaid allowable purchase price of the item; whichever is less.
b. Unless the item is identified by Nevada Medicaid as a rental only, once the total cumulative rental payments have reached the lower of UCC or maximum Medicaid allowable purchase rate, the item is considered purchased in full and recipient-owned.
c. The provider shall automatically transfer the title for the equipment to the recipient. Providers are not to submit prior authorization to transfer titles.
Providers are also not to submit prior authorizations coded as a purchase after the lower of UCC or Medicaid allowable purchase rate is reached. No rental or purchase payments will be made for the remaining reasonable useful lifetime of the device (usually not less than five years (60 months)). The provider’s records must include the date the title was transferred to the recipient.
d. When an item was new at the time of issuance, and it is later determined the recipient will need the item long term, rental payments will be applied toward the total purchase rate (either the provider’s UCC or the Medicaid allowable). Refer to “Purchase Used Equipment Option” in Section 1303.
e. Equipment that was not new at the time of issuance, such as items from the provider/supplier rental fleet, supplied as a temporary short term rental item
must be replaced with new equipment as soon as it is identified the recipient will need the device long term (no later than in the sixth month of rental). Payments made on rental fleet-type items will not be applied to the purchase price of a new item. Purchase or transfer of titles to recipients when the used equipment is from a rental fleet is not allowed.
f. For this option, non-routine maintenance and servicing or repairs may be covered for service dates after the item is owned by the recipient; no sooner than the month following the last rental month.
5. Rental Only Option:
a. Certain items are identified by Nevada Medicaid as a rental only. For these items, a monthly rental will be allowed as long as the recipient continues to meet all qualifications and requirements, and the recipient continues to use the device.
b. For this option, the DMEPOS supplier retains ownership of the equipment, regardless of the length of rental. As the owner, the DMEPOS supplier is responsible to ensure the equipment remains in safe working condition for the reasonable useful lifetime of the device. The rental rates include all supplies and accessories, repairs including routine and non-routine maintenance and servicing, and replacement of items when needed.
Monthly Rentals
One unit should be billed for each month the item is rented, with the exception of the daily rental codes below. The maximum allowable for the rental is for a whole month. A Calendar Month is the period of duration from a day of one month to the corresponding day of the next month and is determined based on the “From” date reported on the claim. If a code is submitted with modifier RR with units greater than 1, or multiple times during the same Calendar Month, Blue Cross and Blue Shield of Louisiana will only reimburse one monthly rate per Calendar Month to the Provider except for daily rental codes as noted below.
Providers must use modifier UE (used durable medical equipment) when billing for used equipment. Used equipment will be reimbursed at a 25% discount.
Deluxe/Luxury and Special Features
Certain DME is considered “deluxe” equipment due to its mechanical or electrical feature(s). For example, electric hospital beds are considered to be deluxe equipment. Deluxe equipment is covered only if Blue Cross determines that the deluxe equipment is both medically necessary and therapeutic in nature. Deluxe equipment ordered primarily for the member’s comfort and convenience and determined to be not medically necessary and therapeutic will not be paid.
When the member requests deluxe equipment, and the medical necessity for the deluxe feature(s) of covered DME is not documented, benefits will be based on the rental or purchase allowance for standard/economical equipment.
A DME provider may deliver deluxe/luxury items as long as they could provide a standard product and the member or her/his representative has specifically requested the excessive or deluxe items or services with knowledge of the amounts to be charged. An Advance Beneficiary Notification (ABN) is required as documentation that the member has made such an informed request. If the ABN has been obtained, the DME/HME item would be submitted to Blue Cross with a Modifier GA appended as informational. The member is financially responsible for the difference in the allowable charge for the standard equipment and the billed charge and is not to be held financially responsible for the discounted amount agreed to in your provider contract. The charge to the member for the difference should be calculated based on the following example:
DME offers a standard item at $500 and a deluxe item at $800. The Blue Cross allowable is $375. The member’s additional out of pocket cost is $800-($500-375) plus any deductible, coinsurance or copay. Due to certain conditions, illnesses or injuries, medical necessity may require DME with special or customized features. All equipment of this type is subject to individual payment consideration and prior approval of Blue Cross.
Charges for rental equipment accessories should be included in the rental price of the equipment with no separate or itemized billing when submitting claims for consideration to Blue Cross. All DME requests for special or customized features should be submitted to the Blue Cross Medical Review Department for prior approval using the Medical Certification Form.
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