Navigating Durable Medical Equipment (DME) Orders

Insurance plans cover durable medical equipment (DME) and supplies when medically necessary, and orders must meet certain requirements for approval.

Helpful Highlights

  • Your loved one's provider determines what durable medical equipment (DME) and supplies are medically necessary.

  • With a properly completed DME/Supply order from the provider, your loved one's health plan will likely cover most or all of the cost.

  • There are several pieces of information required in a DME/Supply order and if any of them is missing, the order cannot be approved and will be returned unfulfilled.

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What information is required on a DME/Supply order?

  • Date

  • Patient's legal name

  • Patient's date of birth

  • DME-related diagnosis and associated ICD-10 codes

  • Provider's NPI number

  • Requested DME/Supply product(s)

  • Length of need/# of refills

  • Provider signature with date

In what circumstances is additional information required?

HEAVY DME items (wheelchair, hospital bed, lifts, etc.) will need to include:

  • Member height and weight

  • Provider reason for the DME item

  • Associated provider progress notes/chart notes

WOUND CARE items will need to include:

  • # of refills (if applicable)

  • Associated provider progress notes/chart notes

  • Location and measurements of the wound

*Note that a new order is required for continuations (continuation is needed after all refills have been utilized).

What happens if any information is missing?

If any information is missing, the DME/Supply request will not be approved. It will be sent back, and the missing information will need to be included and the order resubmitted.

The health plan does not determine what information is required. That is determined by the regulatory agencies that oversee the prescription fulfillment process. The health plan must follow the guidelines set forth by these agencies.

Therefore, if the DME/Supply request is missing any required information, the health plan is obligated to reject it for being incomplete.

If an order is rejected for being incomplete, the health plan takes action to help your loved one. The health plan makes several attempts (phone, fax) to contact the ordering provider. During this time, you and your loved one are also encouraged to contact the provider. If after these attempts the provider has not resubmitted a corrected order, the health plan will notify the member and the provider by mail.

After that point, a new DME/Supply request will need to be submitted.

Approval determination

Once a proper DME/Supply request is received, the health plan has a limited amount of time - typically up to 14 days - to determine approval.

Many health plans do not communicate that the order has been approved. Your loved one is likely to find out that the order has been approved when the supplier contacts them to report that their order has been received or is being filled or is being shipped.

Is your loved one on a VNS Health plan?

If yes, and you have an electronic or hard copy DME order in hand, you can click here to submit that DME/Supply order directly through the DME benefit in our app.

No content in this app, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.

Likewise, no content in this app, regardless of date, should ever be used as a substitute for direct advice from a licensed insurance broker or other qualified plan-payer professional.

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