September 3, 2021

Reimbursement for Durable Equipment (DE) and Durable Medical Equipment (DME), Prosthetics, Orthotics and Supplies (DMEPOS) is established by an all-inclusive DMEPOS fee schedule. Currently, the reimbursement rates are based on Medicare’s DMEPOS and Parenteral and Enteral Nutrition (PEN) fee schedule amount. If there is no Medicare rate, the DE or DMEPOS item or service will be reimbursed using state prevailing rates.

Starting November 11, 2021, reimbursement rates will use the following methodology:

• The reimbursement rate is based on Medicare’s DMEPOS and PEN fee schedule amount. The pricing files are available on the CMS website
• If there is no Medicare rate, the DE or DMEPOS item or service will be reimbursed using TRICARE’s DMEPOS fee schedule rates.
• If there is no Medicare or TRICARE DMEPOS fee schedule rate, the DE or DMEPOS item or service will be reimbursed using state prevailing rates.

When billing DE, DMEPOS, or PEN items, the provider must:

• report the number of units based on the description of the Health Common Procedure Coding System (HCPCS) code and
• always include the modifier code RR on rental items and modifier code UE on used items. Any HCPCS codes billed with the UE modifier will result in a 25% reduction in the purchase rate listed in the TRICARE DMEPOS fee schedule.

The fee schedule and periodic adjustments will be posted on the DHA website

See the TRICARE Reimbursement Manual (TRM) Chapter 1, Section 11 for more information.

Wigs and hairpieces

TRICARE covers one wig (also known as cranial prosthesis) or hairpiece per beneficiary (lifetime maximum) when the attending physician certifies that alopecia has resulted from the treatment of a malignant disease and the beneficiary certifies that a wig or hairpiece has not been obtained previously through the U.S. Government. This includes the Department of Veterans Affairs/Veterans Health Administration (DVA/ VHA). For more information on this benefit, refer to TRICARE Policy Manual (TPM) Chapter 8, Section 12.1

For Calendar Year (CY) 2021, the allowable charge per wig or hairpiece cannot exceed the published CY rate of $2,388. If the wig or hairpiece exceeds this maximum amount, the reimbursement will be up to the allowable amount. The government will update this amount annually, using the Consumer Price Index-Urban (CPI-U), and publish them online