DME Rent to Purchase

Reimbursement Policy:
DME Rent to Purchase

Effective Date:
February 1, 2011

Last Revised Date:
May 1, 2015

Purpose:
Provide guidelines for the reimbursement of DME rent to purchase items, from the same provider and immediately following a period when the DME was rented, for participating and nonparticipating providers (professional & facility).

Scope:
All products are included, except

• Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
• COB

All Insured and Administrative Services Only (ASO) accounts are included.

Policy:
Horizon BCBSNJ requires that procedure codes included on claims for DME rent-to-purchase items are appended with the appropriate modifier as noted below.

DME rent-to-purchase items shall be rented up to the allowed amount for the purchase price or for 10 months, whichever occurs first, from the same provider and occurring without a lapse in rental service.

Procedure:
When purchasing an item being rented from the same provider without a lapse in the rental service, all prior rental allowances will be credited toward the purchase allowance so that the total accumulated dollar amount paid for the rental never exceeds the actual purchase price of the item.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.

Policy 057_v1.0_07152015