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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)

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.

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.

Submit supporting documentation Certificate of Medical Necessity (CMN) (and/or physician order) electronically through provider self-service in the provider access claims center by clicking on the "send documents" link.

You may also mail or fax in supporting documentation (CMN and/or physician order) to:

TRICARE East Region
PO BOX 202150
Florene, SC 29502-2150

Fax: (877) 489-0037

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.