DME refers to durable medical equipment and/or 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.
Note: Some Durable Medical Equipment, Prosthetics, Orthotics and Medical Supplies (DMEPOS) are a limited benefit.
Certificate of Medical Necessity (CMN) is a document signed by the prescribing provider containing clinical information that supports the need for each item/service/supply requested for a beneficiary.
A physician 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.
At a minimum, the CMN must include:
*Length of need: As a best practice, a length of need should not exceed a 12-month period. If a prescription/order exceed 12 months, the beneficiary should return to his or her PCM annually for assessment of his or her condition and ongoing treatment/needs and obtain a new prescription/CMN if necessary. Length of need should be more than 12 months in the case of lifetime use. (An example of lifetime use would be oxygen. In most cases, if you have a prescription for oxygen you are going to have it for life.)
If there is no length of need on the CMN, the claim will be rejected for missing information.
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.
TRICARE will only cover deluxe, luxury and immaterial features for ADSMs.
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. Refer to the TRICARE Policy Manual, Chapter 8, Section 2.1 for more information.
Providers must obtain a signed TRICARE noncovered services waiver form in advance to collect from the beneficiary without fear of holding the beneficiary harmless for the additional cost due to upgrading.
All TRICARE Prime, TRICARE Prime Remote (TPR) and TRICARE Young Adult (TYA) 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.
Use the code look up tool on provider self-service to determine if a specific DMEPOS is covered or if a referral or authorization is required.
*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.
Referrals and authorizations are generally considered valid for one year. The beneficiary should return to his or her PCM annually for assessment of his or her condition and ongoing treatment/needs and obtain a new referral, if needed.
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. Refer to the TRICARE Reimbursement Manual, Chapter 1, Section 11 for more information.
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.
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.