Home Medical Equipment (HME)

Our general guideline for rental of HME is that we provide benefits for rental, up to the allowable purchase price, if equipment is medically necessary. This includes, but is not limited to, oxygen therapy equipment, CPAP devices and apnea monitors.    

The rental allowance is generally based on 10% of the purchase price allowance. Once the allowable purchase price has been met, we consider the equipment to be purchased with ownership transferring to the member. Denied claims will not be applied to the purchase price allowance. 

If a member rented equipment for a period, and then several months later needs the same equipment again, the number of months the item was previously rented do not count toward the 10-month rental limit. There needs to be at least three months between rental periods for the earlier time frame not to be counted toward the rental-to-purchase time cap. 

For rental equipment, providers must bill for 30-day increments even at the end of the year.   

When a rental unit is not needed for a full month, the unit will be paid based on the time frame the patient has the unit.  The number of units should be adjusted to align with the number of days (partial month) that the member rented the equipment. Blue Cross and Blue Shield of Nebraska (BCBSNE) will prorate monthly rental charges (i.e., apply a daily rate) for HME when usage is terminated for any of the following reasons:  

• Return of the equipment to the provider  
• End of need for the equipment  
• Institutionalization of the covered person  
• Death of the covered person  
• Termination of coverage

A negative pressure wound therapy electrical pump is reimbursed as rental only. 

Modifiers 

A4000 – A8999 A9900 – A9999 E0100 – E9999 L0000 – L9900 Q0479 A9270 – A9300 B4000 – B9999 K0001 – K9999 Q0478 S1034 – S1037

Monitoring Services  

Code A9279 is not for monitoring services provided by the durable medical equipment (DME) supplier and must not be billed separately for monitoring services. The member should also not be charged by the DME supplier for monitoring services, under A9279. 

Ventilators

The backup ventilator should be billed on an additional line with the proper HCPC code, along with the modifier TW to indicate the use of a backup ventilator.

Repair of Equipment

Reimbursement will only be made to an HME or medical supply company for medically necessary repair, adjustments and maintenance of purchased HME.    

While an original item is in the shop, a replacement item can be rented. 

Bill loaned equipment with K0462, noting on the claim what equipment is being repaired or temporarily replaced. The date range on the claim should only be for the days the loan equipment was used.

Place of Service

Bill items purchased by the member and dispensed at your walk-in location with place of service 17 (retail clinic). Bill place of service 12 (home) for items delivered or shipped to the patient’s home. Please note if billed with POS 11, the supply or equipment will deny as content.

When the equipment/supply is purchased in the retail store, the claim must be submitted to the Blues Plan in the state where the retail store is located. For items delivered/shipped to the patient’s home, the claim must be filed to the Blues Plan located in the service area where the member resides.   

Insulin Pump and Supplies 

Invoices

When billing a charge that requires an invoice, make sure the invoice meets required criteria: Failure to follow these instructions may result in the claim being returned or denied. 

• Invoices that do not coincide, within reason, with the date of service. 
• Invoices that are not clearly marked as to what charge it coincides with on the claim. 
• Invoices that are not legible.
• Provider to member invoices are not acceptable. 
• Packing slips, catalog pages, order forms or purchase orders are not acceptable.
• Charges for shipping, handling or tax will not be reimbursed.   
• If a claim has multiple lines requiring an invoice, indicate the page and line number for each charge on the invoice.
• When submitting an invoice for enteral formula the number of calories per container need to be included for pricing.
• When an item does not have a rate, or it is an unlisted code that is not for a drug/biologic, it is priced using one of the following two methods:
  • Provider billing the item is the manufacturer.
    • Reimbursed at 85% of their billed charge.
  • Provider purchased the item from a manufacturer.
    • Providers supplying an item they order on behalf of the member are reimbursed at 135% of their cost.
• Purchase orders are not an acceptable substitute for an invoice. 

Hospital HME Billing

When HME for patient home use is dispensed out of the hospital’s free-standing HME business, the HME should be billed on a CMS-1500 claim form under the HME provider’s name and NPI number. 

Supplies and drugs dispensed during an outpatient hospice visit must be billed separately on a CMS-1500 under the HME provider.    

When HME for patient home use is dispensed from the central supply or PT area of the hospital, the HME should be billed by the hospital on the UB04. 

Any HME equipment or supplies used by an inpatient or acute care facility must be billed to BCBSNE by the facility. The HME provider cannot bill BCBSNE for the equipment and supplies.