A clear, step‑by‑step guide to how coverage, authorizations, and payments work with our DME services.

Quick note: Every health plan is different. We verify benefits and obtain approvals, but final payment decisions are made by your insurance. Estimates are not guarantees of coverage.

How it Works (At a Glance)

1. Prescription & medical notes from your provider confirm medical necessity.
2. Benefit verification: we check your plan for coverage, deductibles, coinsurance, and any prior authorization.
3. Authorization & documentation: we gather what your plan requires and submit for approval when needed.
4. Delivery & training: equipment is delivered, fitted, and you receive usage instructions.
5. Billing: we bill your insurer; you may receive a statement for your portion after the insurer processes the claim.

Step‑by‑Step: From Order to Billing

1) Prescription & Face‑to‑Face Visit

• Your clinician provides a written prescription with diagnosis and the specific item(s) prescribed (often by name or HCPCS code).
• Many plans require a recent face‑to‑face visit documenting why the equipment is medically necessary (e.g., mobility limits, sleep apnea diagnosis, oxygen testing results).
• For certain items (e.g., CPAP/BiPAP, oxygen), additional testing or clinical notes may be required.

2) Insurance Benefits Check

• We contact your plan to confirm:
  • Coverage for the prescribed item(s)
  • Deductible status and coinsurance/copay
  • Rental vs. purchase rules
  • Same or similar equipment history (some plans limit how often items can be replaced)
  • Prior authorization needs and any special criteria
• You’ll receive a cost estimate based on what your plan shares with us.

3) Prior Authorization (If Required)

• If your plan requires approval before delivery, we submit the authorization with supporting documentation.
• Timing varies by plan. We’ll update you if anything else is needed from your provider.

4) Documentation We Collect

• Prescription with diagnosis and item(s)
• Recent chart notes supporting medical necessity
• Test results or reports (e.g., sleep study, oxygen saturation testing)
• For mobility items: mobility assessment and home environment info
• For Medicare and some plans: specific coverage criteria must be clearly documented in the visit notes.

Good to know: Some plans no longer require legacy forms (e.g., CMN/DIF), but medical necessity must still be documented in the chart notes. Requirements vary by plan.

5) Order Confirmation & Patient Responsibility

• Before delivery, we review:
  • Your estimated out‑of‑pocket costs
  • Any non‑covered features or upgrades you may choose
  • Financial consent forms (for Medicare, an ABN may be used when an item may not be covered or an upgrade is requested)

6) Delivery, Setup & Training

• We schedule delivery or pickup.
• You’ll receive setup, fitting, and training on safe use and maintenance.
• We obtain proof of delivery and required signatures.

7) Compliance & Follow‑Up (for certain items)

• Some plans require usage compliance in the first 1–3 months (common for sleep therapy devices).
• We provide support, supplies, and education to help you meet your plan’s requirements.

8) Claims & Billing

• After delivery, we submit a claim to your insurer with the appropriate HCPCS codes and modifiers (e.g., RR for rental, NU for new equipment, UE for used).
• Your insurer issues an Explanation of Benefits (EOB) showing what they paid and what you may owe.
• If there is a patient balance (deductible/coinsurance/non‑covered), we will send a patient statement.

9) Reorders, Repairs & Replacements

• Many supplies have refill schedules (e.g., masks, tubing, cushions). We follow plan timelines to avoid early refills.
• Repairs or replacements may require new documentation or approvals. Contact us if something breaks or is lost.

What Insurance Typically Covers

Insurance generally covers DME that is medically necessary, reasonable, and primarily used in the home. Coverage may include:

• Capped rentals (e.g., standard wheelchairs, hospital beds): the plan rents monthly up to a capped period, then ownership may transfer per plan rules.
• Purchase items (e.g., walkers, commodes) that are bought outright when eligible.
• Ongoing service items (e.g., oxygen) with separate monthly billing rules.

Upgrades & deluxe features (like premium cushions or cosmetic options) are often not covered. You may elect to pay the difference; we’ll explain options in advance.

Your Out‑of‑Pocket Costs

Your costs depend on your plan and the item:

• Deductible: the amount you must pay before your plan pays benefits.
• Coinsurance/Copay: your share after the deductible (e.g., a percentage of the allowed amount).
• Non‑covered items: accessories, upgrades, or convenience features may be billed to you.
• Rental vs. purchase: rentals mean monthly patient portions until the rental period ends.

We’ll provide an estimate up front and a statement after your insurer processes the claim.

Rental vs. Purchase: What to Expect

• Rental items: billed monthly to your plan; you may see small monthly statements for your share.
• Capped rental: after a set number of paid months, ownership may transfer (varies by plan).
• Purchase items: billed once; you may see a single statement for your portion.
• Oxygen & certain therapies: special monthly rules may apply.

Common Insurance Terms (Plain English)

• HCPCS Code: a standardized code that identifies your equipment for insurance.
• Modifier: adds details to the code (e.g., RR = rental, NU = new).
• Prior Authorization: insurer approval before delivery.
• Medical Necessity: your provider’s notes explain why the item is needed.
• Same or Similar: insurers may not cover another device if you recently received a similar one.
• ABN (Medicare): a form that explains if Medicare may not pay and outlines your choices.

What We Need From You

• Your insurance card (front and back) and any secondary coverage
• Prescription from your provider
• Your contact info and delivery address
• Any testing or clinical reports your plan requires
• Timely responses to help us obtain approvals and schedule delivery

Providers: How to Refer

Please include:

• Patient demo & insurance
• Recent face‑to‑face chart note supporting medical necessity
• Prescription with diagnosis and item(s)/settings
• Relevant test results (sleep study, oximetry, wound measurements, mobility assessment)
• Contact for clinical questions

Fax or e‑prescribe to: [Fax/E‑Rx details]
Questions? [Billing/Intake phone & email]

Reading Your EOB & Statement

• EOB (Explanation of Benefits) is not a bill; it shows what your insurer allowed and paid.
• Your statement reflects your portion after insurance decisions.
• If something looks off, call us—we’ll help review coverage, authorizations, and coding.