Durable Medical Equipment, Prosthetics, Orthotics and Medical Supplies
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Some durable medical equipment, prosthetics, orthotics and medical supplies (DMEPOS), also known as durable equipment, are a limited benefit. TRICARE defines covered DMEPOS as:
- Medically necessary and appropriate for the treatment of an illness or injury. Must improve the function of a malformed, diseased or injured body part, or reduce further deterioration of the patient's physical condition.
- Able to withstand repeated use.
- Primarily and customarily to service a medical purpose rather than primarily for transportation, comfort or convenience.
- For the specific use by the beneficiary.
View additional limitations for prosthetics, orthotics, hearing aids, and wigs on our Benefits A–Z. Additionally, a few common exclusions are listed at the bottom of this page.
All TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime beneficiaries require an approval from Health Net Federal Services, LLC (HNFS) for all* DMEPOS items. If an approval is not on file, Point of Service charges may apply. If the purchase price of an item is $2,000 or greater, and an approval is not on file, a 10 percent penalty will also apply.
A TRICARE-authorized DMEPOS provider can submit a request for services. The request must demonstrate the DMEPOS is ordered by a physician from the beneficiary's military treatment facility, the primary care manager (PCM) or the specialist who has received an HNFS approval.
Physicians, dentists or any TRICARE-authorized allied health care professional may order or prescribe DME/DE when acting within the scope of their license or certification, including:
- certified physician assistants
- certified clinical nurse specialists when recognized by TRICARE as:
- certified nurse practitioners,
- certified nurse midwives or
- certified psychiatric nurse specialists
- certified registered nurse anesthetists
- certified psychiatric nurse specialists
- licensed physical therapists
- licensed and registered occupational therapists
All orders/prescriptions* are considered valid for one year. A beneficiary should return to his or her PCM annually for assessment of his or her condition and ongoing treatment/needs.
*DMEPOS items considered inexpensive according to Centers for Medicare and Medicaid Services (CMS) guidelines, such as gauze, tape and crutches, do not require a referral from HNFS. (Check the CMS DMEPOS Fee Schedule for details.)
Any DMEPOS with a purchase price of $150 or greater and all rental items regardless of the price require a certificate of medical necessity (CMN) be submitted with the claim (unless prior authorized). No specific CMN form is required. All CMN documents should be considered part of the beneficiary's medical record and retained according to CMS guidelines. The CMN should include:
- type of DMEPOS equipment,
- diagnosis/reason DMEPOS is needed,
- length of time the equipment is needed,
- start date/prescribing date, and
- provider name or signature (must be an MD, DO or allied health care professional)
Note: Podiatrists can order prosthetic and orthotic devices and supplies within the scope of their license.
Payment for a DMEPOS item will be the lower of the total rental cost for the period of time the item is needed or the reasonable purchase price. Some DMEPOS items may be designated as a capped rental. Reimbursement for these items are either paid monthly as a rental with the total purchase price spread over 15 months or as a purchase spread over 13 months. Reimbursement of a capped rental item will be made while the beneficiary maintains TRICARE eligibility.
Note: Items such as a complex rehabilitative power wheelchair and accessories may be excluded from prorated payment and allowed as a lump sum payment for purchase.
Reimbursement is based on the CMS DMEPOS Fee Schedule at cms.gov.
Durable medical equipment items with additional, upgraded features may be covered if the prescription specifically states the medical reason why an upgrade is necessary and meets criteria for coverage.
When a beneficiary prefers to upgrade his/her DME item, which otherwise meets the DME requirements, or obtains equipment with deluxe, luxury or immaterial features that lack documentation of medical necessity for those features, the beneficiary is responsible for the costs that exceed the amount that would be covered for the standard equipment. Providers may collect this payment from the beneficiary only when a request for non-covered services form is completed. The claim must be submitted with a GA modifier for the line item covered by the beneficiary and a GK modifier for the line item covered by TRICARE.
Some DMEPOS are customarily rented due to the cost of the item and/or the length of time the beneficiary requires the item. It is important to note rental costs will not be paid once the total rental allowed amounts reach the TRICARE allowed amount for the purchase price of the item. Once TRICARE has allowed the purchase price, the provider must consider the item purchased and may not continue to bill rental charges. (See oxygen concentrator exception below.)
- All TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime beneficiaries require an approval from HNFS for all rented DMEPOS items.
- Durable medical equipment that generally exceeds more than $100 and is not customized for individual beneficiaries is often rented rather than purchased through DMEPOS suppliers.
Rental reimbursement exception: When oxygen concentrators are cost-shared on a rental basis, the DME cost-sharing policy will not apply even though the purchase price for this equipment has been reached.
Repairs and Replacements
Benefits are allowed for repair of beneficiary-owned DMEPOS when it is necessary to make the equipment serviceable. This includes the use of temporary replacement items provided during the period of repair. The DMEPOS provider is responsible for all repairs of rental equipment. All TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime beneficiaries require an approval from HNFS for all repairs.
Replacement DMEPOS is allowed for beneficiary-owned DMEPOS when the DMEPOS is not serviceable due to normal wear, accidental damage or a change in the beneficiary’s condition. Documentation must be submitted with the claim indicating the reason replacement is required. The DMEPOS provider is responsible for all replacement parts for rental equipment.
The following are a few regularly requested items that are excluded from TRICARE coverage (this list is not all inclusive).
Shipping and handling, sales tax, delivery, labor required for assembly or fitting, pick-up charge, and restocking charges are not a covered benefit.