MEDEQUIP patient GUIDE ·

Why a covered DME code may still be denied

A plan may cover a type of equipment while applying separate rules to your diagnosis, surgery, supplier, documentation, and actual claim.

Five questions to ask ↓Ask Medequip to contact you

THE SHORT ANSWER

A benefit is only the starting point

An insurance representative may confirm that a durable medical equipment (DME) billing code is a covered benefit under your plan. That does not confirm payment for the equipment you receive. In order to get an accurate answer, you will need to ask about the specific HCPCS code and diagnosis or procedure you are having. That’s where Medequip’s years of expertise come into play. We will do all of the heavy lifting up front to confirm authorization requirements, and whether the item will be covered in your specific situation.

CODE VS. CLAIM

What each answer actually tells you

“The code is a covered benefit”

A HCPCS code describes an equipment or service category. It tells you that the plan may have a benefit for that category, subject to its policy terms.

“My specific order qualifies”

The plan may also assess medical necessity, diagnosis, procedure, supplier network, prescription and records, timing, authorization, rental limits, and eligibility.

Even a covered claim may leave a deductible, copayment, or coinsurance.

A CONCRETE EXAMPLE

Knee CPM and E0935

E0935 describes a continuous passive motion (CPM) device for the knee. Under Medicare’s national coverage policy, home CPM coverage is dependent on the patient having a total knee replacement, which must begin within two days after surgery. Therefore, Medicare will not cover a knee CPM for any other knee surgery, or if the CPM rental starts more than two days after surgery. In this case, the details matter.

BEFORE DELIVERY

Five questions to ask your plan and supplier

01

Is this item covered for my diagnosis and procedure?

Give the plan the device name or HCPCS code and the reason it was prescribed.

02

Is Medequip in network for this plan and location?

A supplier appearing on a general network list does not settle your individual benefits.

03

What records or authorization are required?

Ask whether an order, clinical notes, prior authorization, or other documents are needed before delivery.

04

Is this a rental or purchase?

Confirm any time limit, return process, and how the cost is calculated.

05

What should I expect to pay?

Ask about deductible, copayment, coinsurance, upgrades, and what happens if a claim is denied.

How Medequip can help

Medequip’s experienced billing team will do a detailed benefits verification by reviewing your insurance information, medical records, physician prescription, and insurance medical policy. Our team will handle the front-end, and provide you coverage details and an estimate of patient responsibility.

See the patient order process, product guides, and network information. Providers can use our referral resources.

COMMON QUESTIONS

A few important distinctions

Does prior authorization guarantee payment?

No. Authorization and claim payment are separate decisions. Eligibility, the delivered item, documentation, and plan terms still matter.

Where can my clinician find referral information?

Our provider resource page lists information that helps us review an order.

WE’RE HERE TO HELP

Discuss an equipment order

Call 800-944-3422 or request that our team contact you. We can explain the next step for a specific order without promising a claim outcome.

Request a conversation

Use this form for a general callback or email request.