Durable Medical Equipment (DME)

DME reimbursement/claims tips and guidelines

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (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 DMEPOS items.

CMS updates these rates quarterly during the year. Inclusion or exclusion of a reimbursement rate does not imply TRICARE coverage.

 

DME claims

Please mail requests to:

TRICARE East Region claims
ATTN: Correspondence/Corrected claims
P.O. Box 8923
Madison, WI 53707-8923

If you submit on paper, you may include the supporting documentation with the claim; however, there is no guarantee the documentation will be kept with the claim once it arrives in the mailroom at WPS.

 

Billing guidelines regarding upgraded DME

Effective 03/03/2013, TRICARE allows the GA and GK modifiers for DME claims processing. This change allows for the recognition, but not payment of, upgraded DME items, except under certain circumstances. Providers are to bill codes with the GA and GK modifiers to indicate which service is the actual equipment ordered and the upgraded equipment ordered.

  • GA: This is the modifier to indicate the upgraded equipment
  • GK: This is the modifier to indicate the actual equipment

If the patient is not an ADSM, there must be both a ‘GA’ and a ‘GK’ modifier on the claim to indicate which service is the actual equipment and which service is the upgraded equipment. Providers will only be paid for the actual equipment.

Note: 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 EOB and remit.

If the patient is an Active Duty Service Member (ADSM) and there is an authorization, the claim will process, even if the GA modifier is present. Costs for repairs for upgraded items that TRICARE did not purchase are also the responsibility of the beneficiary.

TRICARE claims information