BCBSM updating refill requirements for DME/P&O, medical supplies

Effective July 1, 2014, Blue Cross Blue Shield of Michigan will align with the Centers for Medicare & Medicaid Services’ policy on refill requirements for all durable medical equipment, prosthetics and orthotics, and other medical supplies.

For DME, P&O and supplies that are provided as refills to the original order, suppliers must contact the patient prior to dispensing the refill. Suppliers aren’t allowed to automatically ship the products on a predetermined basis, even if authorized by the patient or designee. This will be done to ensure that:

• The refilled item remains reasonable and necessary
• Existing supplies are nearly expired
• Any changes or modifications to the order are confirmed

Contact with the patient or designee regarding refills must take place no sooner than 10 calendar days prior to the delivery or shipping date.

The supplier must deliver refills of DME, P&O and supplies prior to the expiration of the current product. This is regardless of which delivery method is used. Suppliers must follow BCBSM billing guidelines for dispensing supplies.

Inclusionary guidelines
For all DME, P&O and supplies that are provided on a recurring basis, suppliers are required to have contact with the patient, caregiver or designee prior to dispensing a new supply of items. Suppliers aren’t allowed to deliver refills without a refill request from a patient. Items delivered without a valid, documented refill request will be denied as unreasonable and unnecessary.

Suppliers aren’t allowed to dispense a quantity of supplies exceeding a patient’s expected usage. Suppliers must be aware of any patients whose usage patterns have changed or become atypical. Suppliers must verify with the ordering physicians that any changed or atypical usage is warranted. Regardless of usage, a supplier isn’t allowed to dispense more than the approved monthly quantity at a time.

Documentation requirements
A new prescription isn’t required for routine refills. A new prescription is needed when:

• There is a change of supplier.
• There is a change in the treating physician.
• There is a change in the item(s), frequency of use or amount prescribed.
• There is a change in the length of need or a previously established length of need expires.
• State law requires a prescription renewal.

For items that the patient obtains in person at a retail store, the signed delivery slip or copy of itemized sales receipt is sufficient documentation of a refill request.

For items that are delivered to the patient, the refill request must occur and be documented before shipment. The documentation of a refill request must be either:

• A written document received from the patient
• A recent written record of a phone conversation or contact between the supplier and patient

A retrospective attestation statement by the supplier or patient isn’t sufficient. The refill record must include:

• The patient’s name or authorized representative for the patient
• A description of each requested item
• The date of the refill request
• The quantity of each item that the patient still has remaining

This information must be kept on file and be available upon request.