which medicare contractor covers ky dme purchases

How does Kentucky Medicaid identify durable medical equipment (DME) suppliers?

Kentucky Medicaid identifies durable medical equipment (DME) suppliers as Provider Type (90). To enroll and bill Kentucky Medicaid DME suppliers must be: Out-of-state providers may enroll but must be licensed by the state where they practice. In Kentucky, DME service providers must be licensed with the Kentucky DME Suppliers

Does Medicare cover DME suppliers?

To find out if Medicare covers the equipment or supplies you need, or to find DME suppliers in your area, call 1-800- MEDICARE or visit www.medicare.gov. You can also learn about Medicare coverage of DME by contacting your State Health Insurance Assistance Program (SHIP).

How do I become a DME provider in Kentucky?

In Kentucky, DME service providers must be licensed with the Kentucky DME Suppliers Enrolled as an active Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves.

What is a Medicare DME agreement?

DME that Medicare covers includes, but isn't limited to: An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.

Which plan covers DME drugs for Medicare?

Medicare Part BAnyone who has Medicare Part B (Medical Insurance) can get DME as long as the equipment is medically necessary.

What is a Mac Medicare administrative contractor?

A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.

Which Medicare contractor processes and pays for Medicare claims?

There are two main types of Medicare administrative contractors (MAC): A/B MACs, who handle Medicare Part A and Part B claims and Medicare appeals for inpatient and outpatient care and services, as well as hospice and home health care.

What Medicare jurisdiction is Kentucky?

Jurisdiction BJurisdiction B is serviced by CGS and includes Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin.

What is the difference between RAC and MAC?

MAC audits are powerful and intrusive procedures that have the potential to lead to serious federal charges for healthcare entities. A Recovery Audit Contractor (“RAC”) reviews claims and identifies overpayments from Medicare so that CMS and other auditors are able to prevent improper payments in the future.

What does a Zone Program Integrity Contractor do?

The Zone Program Integrity Contractor (ZPIC) is an entity established in the United States by the Centers for Medicare & Medicaid Services (CMS) to combat fraud, waste and abuse in the Medicare program.

What is a unified program integrity contractor?

UPICs were created to perform program integrity functions for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice, Medicaid and Medicare-Medicaid data matching.

Which has been replaced with Medicare administrative contractors?

In 2003 the Centers for Medicare & Medicaid Services (CMS) was directed via Section 911 of the Medicare Prescription Drug Improvement, and Modernization Act (MMA) of 2003 to replace the Part A FIs and Part B carriers with A/B Medicare Administrative Contractors (MACs) in accordance with the Federal Acquisition ...

Who owns novitas solutions?

Diversified Service Options, Inc.Novitas Solutions, Inc. is a wholly owned subsidiary of Diversified Service Options, Inc., doing business as GuideWell Source, a subsidiary of GuideWell Mutual Holding Corporation.

What states are in Medicare jurisdiction C?

DME MAC Jurisdiction C – DME Facts JC processes FFS Medicare DME claims for Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia, and West Virginia.

What states are in Medicare jurisdiction D?

DME MAC Jurisdiction D – DME Facts JD processes FFS Medicare DME claims for Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington, and Wyoming.

What is Medicare jurisdiction A?

United StatesCenters for Medicare & Medicaid Services / Jurisdiction

What is KY Medicaid?

Kentucky Medicaid utilizes the National Correct Coding Initiative (NCCI) edits as well as the McKesson Claim Check System to verify codes that are mutually exclusive or incidental. Kentucky Medicaid also uses Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding system (HCPCS) codes. Kentucky Medicaid requires the use of ICD-10 codes on all claims submitted for reimbursement. Kentucky Medicaid requires the use of CMS 1500 billing forms. Providers will need to bill Kentucky Medicaid using the correct CPT codes.

How long does it take to get a Kentucky Medicaid claim?

Claims must be received within 12 months of the date of service (DOS) or six months from the Medicare pay date whichever is longer, or within 12 months of the last Kentucky Medicaid denial. Please refer to the MCO if appealing a claim.

What is covered services?

Covered Services. DME is equipment that withstands repeated use and is used primarily to serve a definite medical purpose. It generally ia not useful to a person in the absence of an illness or injury.

Can out-of-state providers enroll in Medicaid?

Out-of-state providers may enroll but must be licensed by the state where they practice. In Kentucky, DME service providers must be licensed with the Kentucky DME Suppliers. Enrolled as an active Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves.

Is listing a service in an administrative regulation a guarantee of payment?

Any services performed must fall within the scope of practice for the provider. Listing of a service in an administrative regulation is not a guarantee of payment. Providers must follow Kentucky Medicaid regulations. All services must be medically necessary.

Can you get reimbursed for a service provided to a beneficiary by more than one provider?

The department will not reimburse for a service provided to a beneficiary by more than one provider of any program in which the same service is covered during the same time period.

Does Medicaid cover wheelchairs?

Medicaid covers DME such as wheelchairs; hospital beds; orthotic appliances (foot/leg braces); and prosthetic devices (artificial limbs), etc., and disposable medical equipment ordered by an accepted prescriber that is medically necessary and suitable for use in the home.

What is Medicare Coverage for Durable Medical Equipment (DME)?

What is Medicare Coverage for Durable Medical Equipment (DME)? Whether you use a walker, a blood pressure monitor, crutches or other items that are used to improve your health, there’s no doubt that having access to medical equipment can improve your quality of life and maybe even save it.

How does Medicare cover durable medical equipment (DME)?

Original Medicare uses the term “durable medical equipment” or “DME” to refer to medical equipment items it covers. Durable medical equipment as it pertains to Medicare includes items that are intended for repeated use. Per this definition, single-use items are usually disqualified from DME coverage.

What Part of Medicare Covers Durable Medical Equipment?

Medicare benefits are supplied via different parts of the program. Medicare Part B is the outpatient benefit and covers not only things like doctor visits and surgery, but it also covers DME. For most Medicare recipients, DME is covered at the standard Part B rate of 80%.

Rentals vs. Purchases

In some cases, a piece of DME will need to be rented prior to a full purchase being covered. Medicare Part B usually covers rentals of DME that are eligible for purchase, but timeframe requirements for rentals before purchase may vary.

Non-Prescription Durable Medical Equipment

It’s important to note that Medicare’s coverage of DME only extends to items which have been ordered by a Medicare-participating physician. This means that you will not be able to receive coverage for items that you purchase on your own, including equipment for sale at retail health stores and pharmacies.

Medicare Advantage Coverage for DME

Medicare Advantage plans must include the same Part A and Part B benefits as Original Medicare, but many plans offer additional coverage. Check with your plan directly for questions regarding your DME. You may need to get your equipment from a supplier within your plan’s network.

How long does Medicare pay for a wheelchair?

Most equipment is initially rented, including many manual and power wheelchairs. Original Medicare covers 80% of the cost of a monthly rental fee for 13 months. You pay a 20% coinsurance. After 13 months, ownership is typically given to you automatically.

Does Medicare pay for oxygen equipment?

Note: There are different rules for oxygen equipment. If you have Original Medicare, you will typically pay the least if you order your DME from a Medicare-approved supplier who takes assignment . If you have a Medicare Advantage Plan, make sure to follow your plan’s coverage rules.

Modifier KY

Some competitively bid wheelchair accessories can be used with both competitively bid and non-competitively bid wheelchair base units.

Correct Use

Append when billing for competitively bid (Round 2 or subsequent Round) wheelchair accessories used with certain non-competitively bid wheelchair base units for beneficiaries residing in Round 2 (or subsequent Round) competitive bidding areas (CBAs)

Who is the key to Medicare?

The attending physician is ALWAYS the key to obtaining Medicare benefits; obtain a statement from the beneficiary’s physician stating that the durable medical equipment prescribed is medically necessary, is part of his course of treatment, and explaining its therapeutic value to the beneficiary.

How long does Medicare expect to pay for equipment?

Medicare expects a piece of equipment to last 5 years and will not usually pay for like or similar equipment within that time frame; and. It must be appropriate for use at home. Under a provision of federal law, a skilled nursing facility is not considered home; and.

How much does Medicare pay for a chair?

If the beneficiary decides to purchase the chair, Medicare will pay 80% of the allowable purchase price in a lump-sum amount. The beneficiary is responsible for the 20% coinsurance amount and, for unassigned claims, the balance between the Medicare allowed amount and the supplier’s charge.

When does Medicare make no rental payments?

Medicare contractors will make no further rental payments to the supplier after the 11 th rental month for capped rental items until the supplier notifies the contractor that it has contacted the beneficiary and given the beneficiary the option to purchase or to continue renting the capped rental.

What is a quick screen for Medicare?

A QUICK SCREEN TO AID IN IDENTIFYING COVERABLE CASES. Medicare claims for DME (Items that have a medical purpose and repeated use) are suitable for coverage, and appeal if they have been denied, if they meet the following criteria: The equipment has been prescribed as medically necessary by your physician. Most items require a Certificate of ...

Does Medicare pay for oxygen equipment?

Purchase of oxygen equipment: o n or after June 1, 1989, June 1, 1989, Medicare no longer pays for oxygen equipment that is purchased. If the beneficiary owns stationary liquid or gaseous oxygen equipment, the Medicare contractor pays the monthly oxygen contents fee.

Does Medicare pay for oxygen concentrators?

For owned oxygen concentrators, Medica re contractors do not pay a contents fee. Whether the beneficiary owns or rents an oxygen concentrator or a stationary gaseous or liquid oxygen system and has either rented or purchased a portable system, Medicare contractors pay the portable oxygen contents fee.

What is assignment in Medicare?

Assignment —An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.

Does Medicare pay for DME repairs?

Medicare will pay 80% of the Medicare-approved amount (up to the cost of replacing the item) for repairs. You pay the other 20%. Your costs may be higher if the supplier doesn’t accept assignment.

Covered Services

Claims Submission

Provider Contact Information

Provider MCO Information

• Anthem - (800) 205-5870 Aetna Better Health of KY -(855) 300-5528 Humana - (800) 444-9137 Molina - (800) 578-0775 WellCare of KY - (877) 389-9457 ​

See more on chfs.ky.gov