Policies & Processes

Qualifying a patient for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) involves following a structured process to ensure compliance with regulations and payer requirements, particularly those set by Medicare and other insurers. Here’s a step-by-step guide:

1. Verify the Patient's Coverage

Medicare: Check if the patient has Medicare Part B, as it covers most DMEPOS items.

Other Insurers: Verify benefits for DMEPOS under the patient's policy.
Confirm the patient's deductible and co-payment responsibilities.
Check for prior authorization requirements.

2. Ensure Medical Necessity

DMEPOS must be medically necessary for the patient. Common criteria include:

The equipment or supplies must be prescribed by a healthcare provider.
They must address a medical condition, injury, or disability.
The item must be used in the patient's home setting.

Collect relevant diagnosis codes (ICD-10) and HCPCS codes for billing.

3. Obtain a Valid Order or Prescription

Ensure the order or prescription includes:

Patient’s full name and DOB.
Specific name and description of the equipment/supplies.
Detailed medical justification (e.g., why a wheelchair is needed versus a cane).
Prescribing physician’s signature and NPI number.
Date of the prescription.

4. Document Supporting Evidence

Collect all necessary documentation to support the claim:

Clinical Notes: Recent progress notes from the prescribing physician.
Test Results: E.g., sleep studies for CPAP machines, imaging for braces.
Face-to-Face Encounter Documentation: Required for certain DME (e.g., wheelchairs, hospital beds). Must occur within 6 months of the prescription.
Detailed explanation of how the DMEPOS item improves functionality or health.

5. Follow Local Coverage Determinations (LCDs)

LCDs specify coverage criteria for specific items, such as: