DME Table of Contents
Preface Information
- Desk Reference Guide
- Acronyms and Abbreviations
Program Information
- General Program Information
- Program Background and Objectives
- Provider Agreement and Professional Standards
- Payer of Last Resort
- Program Reimbursement
- Payment in Full
- Incorrect Payment
- Claim Submission Timeliness
- Medical and Other Record Content Requirements
- Record Retention Requirements
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- Provider Participation and Enrollment
- Participation
- Enrollment
- Re-certification
- Suspension or Termination
- Electronic Media Claims (EMC) Enrollment
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- Program Communication and Services
- Written Correspondence
- Telephone Inquiries
- Provider Training
- On-Site Visits
- Publications
- Direct Deposit
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- Recipient Eligibility and Identification
- Benefit Levels
- Categorically Needy
- Medically Needy
- Qualified Medicare Beneficiaries (QMBs)
- EPSDT
- Identification Card
- Altered ID Cards and Other Abuses
- Inmates Ineligible for Medical Assistance Program
Benefits
- Recipient Eligibility Verification System (REVS)
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- Flexible Test of Income
- Spend-Down Liability (SDL)
- Determining Payment When a Spend-Down Amount Is
Applied
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- Third Party Liability (TPL) for Medical Expenses
- Claims Filing
- Refunds Resulting From Other Insurance
- Co-insurance and Deductible
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- Services Utilization Review (SURS)
- Review of Services Utilized
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- RIte Care Program
- Overview
- Participating Health Plans
- Eligibility
- Enrollment
- Copayment and Premiums
- Scope of Services
Claim Management Information
- General Billing Information
- Typed and Handwritten Claims
- Submitting Copies
- Attachments for Claims
- Provider Signature
- Correct Postage
- Using a Billing Company
- Requesting Change of Address/Change of Status
- Non-Providers
- Ordering Claim Forms
- Timeliness Requirements
- Hand-Delivered Paper and Electronic Claims
- Claim Form Order Card
- Provider Manual Order Form
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- Out-of-State and Emergency Claims
- Medical Services Provided Outside of Rhode Island
- Prior Authorization
- Exceptions to Prior Authorization
- Circumstances In Which Medical Care Is Provided
- Payments
- Timeliness
- Border Communities
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- Prior Authorization (PA)
- PA Instructions
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- Claim Correction Form (CCF)
- CCF Instructions
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- Remittance Advice (RA)
- Banner Page
- Paid, Denied, Claims in Process
- Adjusted Claims
- Financial Items
- TPL and Medicare
- Earnings Data and Error Messages
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- Paid Claim Adjustments and Refunds
- Single and Multiple Adjustment Request Forms
- Information Required
- Attachments
- Single Adjustment Request Form Instructions
- Multiple Adjustment Request Form Instructions
- Refunds or Recoupments of Paid Claims
- Underpayment
Medical Coverage Policies
Please note that policy and procedures are subject to change. Refer to your
provider update bulletins regarding your provider type.
Certificate of Medical Necessity
Claims Billing Guidelines
Covered or Non-Covered DME Items
Criteria for Covered Items
Activity
Chairs
Air
Fluidized Bed
Alternating
Pressure Mattress/Air Flotation Bed
Pressure
Pads (Air, Gel, Dry, Water, Alternating)/Pumps
Apnea
Monitor
Pneumograms
Bathtub
Seats/Benches, Shower Chairs, Bath Supports
Cane and
Crutches
Car
Seats
Commodes
Continuous
Passive Motion Devices (CPM)
Continuous
Positive Airway Pressure System (CPAP)
Diapers/Underpads/Liners
Eating
Utensils/Placemats, Reachers
Emergency
Response Systems
Enteral
Nutrition
Total
Parenteral Nutrition
Hearing
Aids
Home
Blood Glucose Monitors
Home IV
Therapy
Infusion
Pumps
Hospital
Beds, Cribs, Youth Beds
Incontinence
Appliances And Care Supplies
Intermittent Positive Pressure Breathing System
Lymphedema
Pumps
Nebulizers/Supplies
Osteogenic
Stimulator
Ostomy
Supplies
Orthosis
Oximeters
Oxygen
And Oxygen Equipment
Portable
Oxygen Systems
Respiratory
Therapists
Patient
Lifts
Percussor
Phototherapy
Power
Operated Vehicle
Prone
Standers, Supine Standers, Standing Tables
Prosthesis
Raised
Toilet Seats/Versa Frames/Grab Bars/Portable Shower Heads
Ramps
(Portable)
Rollabout, Mobile Geriatric Chairs
Seat
Lift Chairs/Motorized Mechanisms
Spinal
Orthotics: Seating Systems, Back Module
Suction
Pumps
Surgical
Dressing Supplies
Therapy
Related Equipment
Transcutaneous
Electrical Nerve Stimulators (TENS) And Related Supplies
Trapeze
Bars And Other Bed Accessories
Ventilators
Walker,
Gait Trainers, Support Walkers
Wheelchairs,
Strollers
Custom-Made Equipment
Durable Medical Equipment Reimbursement
Personal Needs in NF or ICF-MR
Prior Authorization
Provider Participation
Service and Repair
Claim Preparation Instructions
CMS 1500 Form Filing Instructions
DME and Hearing Aids – CMS 1500 Claim Form
Error Status Codes
ESC Code List (English)
Explanation of Benefits (EOB) Codes
- EOB Codes and Messages List (English)
- EOB Codes and Messages List (Spanish)
Appendix - Third Party Liability Carrier and Coverage
Codes
- Third Party Liability (TPL) Carrier Codes
- Third Party Liability (TPL) Carrier
Codes (PDF Format)
- Third Party Liability (TPL) Coverage Codes
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For specific questions you may contact the EDS Customer Service Help Desk at
(401) 784-8100 for In-state and long distance callers, or 1-800-964-6211 for In-state toll
callers and border communities. |
