DME refers to supplies that are necessary for the treatment, habilitation or rehabilitation of a beneficiary. The equipment should provide the medically appropriate level of performance and quality for the medical condition present.

Upgraded DME

TRICARE will only cover deluxe, luxury or immaterial features for Active Duty Service Members (ADSM). All other TRICARE beneficiaries who choose to upgrade from a covered DME item to a deluxe, luxury or immaterial feature for comfort or convenience will need to be responsible for the added cost. DME providers must obtain a TRICARE noncovered service waiver signed by the beneficiary in advance in order to collect from the beneficiary without fear of holding the beneficiary harmless for the additional cost due to upgrading.

Certificate of Medical Necessity (CMN)

A CMN is a document signed by the prescribing provider containing clinical information that supports the need for each item, services, or supplies requested for a beneficiary.

A physician’s order or prescription itself can take the place of the CMN as long as it includes the necessary elements and signature. It is very important that the CMN or physician order be complete and current for the services/supplies/equipment to be covered. A copy of the CMN or order must be submitted with the claim. Be sure to keep the CMN on file for at least one year.

A CMN must include:

  • Type of equipment
  • Diagnosis or reason
  • Length of need*
  • Beginning date
  • Physician signature (nurse practitioner and physician assistant signatures are accepted)

*Length of need for Capped DME items should cover a 15 month period.

Any time there is a change in the prescription, the physician must provide an updated or new prescription or CMN for the DME to be submitted for claims.

Some DME, Prosthetics, Orthotics and medical Supplies (DMEPOS) are a limited benefit.

Breast pumps and supplies services are determined by patient/newborn need; physician order/Certificate of Medical Necessity (CMN) requirements apply.

Guidelines MUE vs. DUT Rental vs. Purchase

Referral and authorization guidelines for DME

All TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime beneficiaries require a referral for any DME billed under code E1399 or for any other miscellaneous code. Billed charge is the charge amount or negotiated amount submitted on the claim. E1399 should only be used for special and/or customized equipment for which no other HCPCS code has been assigned.

ADSMs require an authorization for all DMEPOS items (manual or standard electric breast pumps do not require an authorization, but will require a prescription)

Predetermination is available for non-prime beneficiaries

To determine if a specific DMEPOS is covered, or if a referral or authorization is required, use our code look up feature by logging into self-service.

An approved authorization does not take the place of a CMN or physician’s order. A completed and current CMN or physician’s order is required to submit with the claim.

Billing guidelines

All TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime beneficiaries require a referral for any DME billed under code E1399 or for any other miscellaneous code. Billed charge is the charge amount or negotiated amount submitted on the claim. E1399 should only be used for special and/or customized equipment for which no other HCPCS code has been assigned. 
ADSMs require an authorization for all DMEPOS items (manual or standard electric breast pumps do not require an authorization, but will require a prescription)

Predetermination is available for non-prime beneficiaries 
To determine if a specific DMEPOS is covered, or if a referral or authorization is required, use our code look up feature by logging into self-service.

This change in policy affects all DME including eyeglasses and hearing aids. If only one modifier is present the line will deny as needing both modifiers. If both modifiers are present then we will issue payment on the line with the GK modifier as we normally do, and reject the line with the GA modifier indicating it is not medically necessary. This information will also be seen on the Explanation of Benefits (EOB) and remit.

Reimbursement/claims guidelines

DMEPOS fee schedule

TRICARE uses the reimbursement rates established by the Centers for Medicare and Medicaid Services (CMS) or the CMAC state prevailing price for items of DMEPOS. CMS updates these rates twice a year in January and July. Inclusion or exclusion of a reimbursement rate does not imply TRICARE coverage.

If submitting claims electronically, you can fax the supporting documentation (CMN and or physician order) to (608) 221-7542. Please include sufficient information on a cover sheet to match the documentation to the claim. Please be sure to send in within two to four days of submitting the claim.

Not all service units represent the same measure. Please be sure you know what, if any, units are associated with the code you are submitting on a claim. There are specific supplies that are distributed in a measure greater than a daily supply. These items are date spanned. There are very few of these and you should check before submitting a date spanned claim.

Medically Unlikely Edit (MUE) vs. Day Units Time (DUT)

Military hospital or clinic

MUE indicates that it is unlikely that more than X number of an item would be used in a day. This causes confusion as so many items are ordered on a 30-day or even a 90-day basis. DHA has a list of MUEs at TRICARE.mil. It is important to note that not all codes have a DHA determined MUE. Supplies should be filed using the date of service, not a date span, and should indicate the DUTs. (Code A7033 billed with 90 DUTs) Providers need to verify all information on TRICARE.mil before sending to claims processing. This field represents the number of units of an item you are submitting. For example, in the observation world 1 unit = 1 hour.

Do not file claims with future dates.

Not all service units represent the same measure. Please be sure you know what, if any, units are associated with the code you are submitting on a claim. There are specific supplies that are distributed in a measure greater than a daily supply. These items are date spanned. There are very few of these and you should check before submitting a date spanned claim.

Claims denied or rejected due to exceeding MUE/DUT limitations

Requests for reconsideration are an option for providers when services or supplies are denied or rejected due to units or services exceeding the daily limit. Reconsideration is not an option for luxury or upgraded DME items. Reconsiderations must include documentation that supports the units billed, with as much clinical support as possible. Please follow the “reconsideration process” instructions. The coversheet and tips for filing a reconsideration are also available under the forms section of provider self-service. Please do not confuse this with the initial claim filing and supporting documentation. This is a reconsideration process after claims have been denied.

Depending on which is the least expensive for TRICARE, DMEPOS may be leased or purchased. When receiving claims for extended rentals, TRICARE evaluates the cost benefit of purchasing the equipment and will pay only up to the allowable purchase amount.

Repairs

Benefits are allowed for repair of beneficiary owned DME when it is necessary to make the equipment serviceable. This includes the use of a temporary replacement item provided during the period of repair.

Replacements

Benefits are allowed for replacement of beneficiary owned DME when the DME is not serviceable due to normal wear, accidental damage, a change in the beneficiary’s condition or the device has been declared adulterated by the FDA. Exceptions exist for prosthetic devices.

Modifications

A wheelchair, or an approved alternative, which is necessary to provide basic mobility, including reasonable additional cost to accommodate a particular disability, is covered.

In order to be considered a customized item, a covered item (including a wheelchair) must be uniquely constructed or substantially modified for a specific beneficiary according to the description and orders of a physician and be so different from another item used for the same purpose that the two items cannot be grouped together for pricing purposes.

A duplicate item of DME, which otherwise meets the DME benefit requirement that is essential to provide a fail-safe in-home life support system, is covered.