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Covered durable medical equipment (DME) and medical supplies

We cover and reimburse for DME and medical supplies needed by our members. DME may be rented, purchased or rented-to-purchase. For coverage details, you can check the Long-Term Care (LTC) DME fee schedule (PDF) and the Medicaid Managed Medical Assistance (MMA) and Florida Healthy Kids (FHK) DME fee schedule (PDF).

What types of DME and medical supplies are covered?

What types of DME and medical supplies are covered?

Reimbursable equipment and supplies include:
 

  • Augmentative and assitive communication devices
  • Commodes
  • Diabetes equipment and supplies, including blood glucose meters, test strips, syringes and lancets
  • Enteral nutrition supplements
  • Hospital-type beds and accessories
  • Mobility aids including canes, crutches, walkers, and wheelchairs
  • Orthopedic footwear, orthotics and prosthetic devices
  • Ostomy and uroligical supplies
  • Respiratory equipment and supplies, including nebulizers and oxygen
  • Suction pumps
  • Wheelchairs, including custom wheelchairs and accompanying parts - which require prior authorization (PA)

Requirements for coverage

Requirements for coverage

We cover DME and medical supplies that meet these requirements:

 

  • They are consumable, expendable, disposable or non-durable medical or surgical items appropriate for use in your patient’s home.
  • The member has a prescription or hospital discharge orders for the items.
  • The accompanying documentation and Plan of Care is signed by/dated by their provider with specific term, duration and diagnosis

DME pricing, coding and limits

DME pricing, coding and limits

We base reimbursement of DME services on the Florida Agency for Health Care Administration (AHCA) fee schedules. Any code without an assigned rate requires PA and is reimbursed at the manufacturer’s invoice plus 15%.

 

You can find more information about DME and medical supply services on ACHA’s website. You can also review their Durable Medical Equipment and Medical Supplies Benefit Policy (PDF).

 

 

 

Standard limits do not apply for our LTC members, and PA is required for all DME services. Authorization is based on the member's individual needs as assessed on their care plan.

 

We follow the same limits as AHCA’s DME fee schedule. We require that correct coding, when available for a specific item, service or device, be used instead of miscellaneous procedure codes. PA is needed for all requests that go over limits on the fee schedule.

 

Use the CMS 1500 form for DME rental claims. DME rental claims are only paid up to the purchase price of the equipment. Units billed equal the number of days billed. Since appropriate billing for CMS is 1 unit per month, the claim must include the rental’s prescribed date span (from and to date) so the benefit amount payable can be determined. Appropriate modifier, RR, is required for all rentals.

DME maintenance and repair

DME maintenance and repair

DME maintenance and repair is covered under certain circumstances. These are the guidelines:
 

  • Replacement parts or equipment repairs within the first year of service are not covered.
  • Providers may not disregard the DME recipient’s requests for warranty equipment repairs or modifications.
  • Providers may not delay any needed repairs or modifications (otherwise permitted by DME policy) past the provider’s or manufacturer’s warranty expiration date.
  • Reimbursement for DME equipment maintenance is limited to the amount necessary to make the item serviceable and safe, but not to exceed 75% of the original cost of the equipment plus the cost of subsequent modifications in need of repair or renovation.

 

DME maintenance and repair will be reimbursed if it meets all the following criteria:

 

  • Equipment is covered by Medicaid or FHK.
  • Equipment is the personal property of the recipient.
  • Item is still medically necessary.
  • Equipment is used exclusively by the recipient.
  • No other payment source is available to pay for the needed repairs.
  • Equipment damage is not due to misuse, abuse, neglect, loss or wrongful disposition by the recipient, the recipient’s caregiver or the provider.
  • Maintenance is performed by a qualified technician.
  • Maintenance is not currently covered under a manufacturer or provider’s warranty agreement.
  • Maintenance is not performed on a duplicate type of item already being maintained for the recipient during the maximum limit period.

Processing timeline for electronically submitted clean claims

Processing timeline for electronically submitted clean claims

We follow these timelines for electronically submitted DME clean claims:
 

  • Within twenty-four (24) hours after the beginning of the next business day after receipt of the claim: We’ll provide electronic acknowledgement of the receipt of the claim to the electronic source submitting the claim.
  • Within fifteen (15) days: We’ll pay the claim or notify the provider or the designee that the claim is denied or contested. The notification to the provider of a contested claim will include an itemized list of denial reasons or codes and additional information or documents necessary to process the claim.
  • Within ninety (90) days after receipt of the claim: We’ll pay or deny the claim. Failure to pay or deny the claim within one hundred twenty (120) days after receipt of the claim creates an uncontestable obligation for health plans to pay the claim.

Prior authorization

Prior authorization

PA is required for:

 

  • DME purchases over $500

  • Equipment rentals

  • Items that aren’t on the fee schedule

 

You can also check for codes that require PA with our PA search tool. Note that some services are limited to members under age 21. 

You can fax PA request forms (PDF) to:

 

 

You can find more information about the PA process on our prior authorization page. 

 

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