Medicare Advantage durable medical equipment coverage changes

Medicare Advantage Medicare Plus Blue PPO^SM members will have a combined out-of-pocket maximum for durable medical equipment and medical and surgical benefits, effective Jan. 1, 2013. Claims will be processed at the in-network level for members that receive services from in-network DME providers.

Claims
Please send DME paper claims to:

Medicare Plus Blue
Blue Cross Blue Shield of Michigan
P.O. Box 32593
Detroit, MI 48232-0593

Please visit our website at bcbsm.com/provider/ma for information on BCBSM’s electronic billing processes. Call DMEnsion Benefit Management at 1-888-828-7858 from 8:30 a.m. to 5 p.m. Monday through Friday for questions related to dates of service prior to Jan. 1, 2013.

Medicare Advantage claims payment checks are sent once a week.

Eligibility
To verify eligibility or for information related to dates of service Jan. 1, 2013, and after, please call BCBSM Medicare Advantage Provider Inquiry at 1-866-309-1719. You can also access DME information, including member eligibility, online via web-DENIS. Go to bcbsm.com and click on Providers, then select web-DENIS.

Billing
Prescriptions must be written and submitted prior to the member obtaining the DME item, or the member may be subject to pay for that item out of pocket. Please encourage your patients to wait to obtain any DME items until they receive a prescription.

There are times when a Michigan Medicare Advantage member or provider may receive DME equipment or supplies from an out-of-state provider. The out-of-state DME provider will be responsible for submitting claims to BCBSM for processing.

Some DME requires a Certificate of Medical Necessity. A Certificate of Medical Necessity is a form the physician must complete and submit with the DME prescription. It certifies the member’s condition is such that the DME being prescribed is medically necessary.

If a DME supplier bills for items requiring a Certificate of Medical Necessity, the supplier must bill with the KX modifier to indicate a certificate is on file. Current equipment that requires this certificate includes:

• Bone growth (or osteogenesis) stimulators
• Home oxygen equipment and supplies
• Lymphedema pumps and pneumatic compression devices
• Patient lifts
• Transcutaneous electronic nerve stimulators
• Continuous positive airway pressure machines

Special exception items
Some equipment may be covered under certain conditions, even though it does not meet the definition of DME. The following items are covered when it is clearly established that they serve a therapeutic purpose in an individual case:

• Gel pads and pressure and water mattresses (which generally serve a preventive purpose) when prescribed for a patient who has bed sores or when there is medical evidence the patient is highly susceptible to ulceration
• Heat lamps for a medical, rather than a soothing or cosmetic, purpose (such as heat therapy)

In establishing medical necessity for these items, evidence must show that the item is required as part of the physician’s course of treatment and that a physician is supervising its use.

Note: The above items represent special exceptions and no extension of coverage to other items should be inferred.