DME Written Orders - Senior Plans

For durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) to be covered by HMSA’s 65C Plus, the treating physician must give the 65C Plus contracted DME supplier an order for the item before the supplier can dispense the item to a beneficiary. Items dispensed without an order from the treating physician will be denied. Any updates to this policy by Medicare will apply for 65C Plus unless otherwise specified. For questions about Medicare’s requirements, refer to Medicare instructions.

Verbal Orders

Suppliers may dispense most DMEPOS items based on a the physician’s verbal order (except those items requiring a written order prior to delivery listed below). Suppliers must document the verbal order and this documentation must be available to HMSA upon request.

The verbal order must include all the following elements:

• Description of the item
• Name of the beneficiary
• Name of the physician
• Start date of the order

When items that are dispensed based on a verbal order, the supplier must obtain a written order from the physician. The written order must meet the requirements outlined in the next section.

Written Orders

The 65C Plus contracting DME supplier must have a written order that has been signed and dated by the treating physician before submitting a claim to 65C Plus for the item. Written orders may take the form of a photocopy, facsimile image, electronically maintained or original “pen and ink” document. Although it is acceptable to submit a claim based on a facsimile image, electronically maintained or photocopied order, it will be the supplier’s responsibility to validate its authenticity prior to submitting the claim.

Suppliers must ensure the security and integrity of all electronically maintained orders and certificates of medical necessity (CMNs) in accordance with the guidelines published by the Centers for Medicare & Medicaid Services (CMS).

Written orders for DMEPOS items must include the following information:

• Beneficiary’s name and full address
• Detailed description of the item that can either be a narrative description (e.g., lightweight wheelchair base) or a brand name/model number. The detailed description of the item may be completed by someone other than the physician. However, the treating physician must review the detailed description and personally sign and date the order to indicate agreement.
• All options or additional features that will be separately billed or will require an upgraded code
• Signature of the treating physician and date. Both the signature and date must be personally entered by the physician. Signature stamps and date stamps are not acceptable.
• Start date. If the order is for an item that has been dispensed before the date that the detailed written order is signed (e.g., a written confirmation of a verbal order), then the order must clearly specify the initial date of need.
• Length of need (if the coverage criteria in a policy specifies length of need; or if the order is for a rental item)
• Medical necessity information (e.g., a diagnosis code, narrative description of the patient's condition, abilities, limitations, etc.)
• Explanation of how the item(s) is to be used, if appropriate or required by policy

Additional Elements Required in the Written Order for Certain Items

The following information is also needed for accessories or supplies that will be provided on a periodic basis:

• Quantity used
• Specific frequency of change or use (Note: “as needed” or “prn” orders are not acceptable.)
• Length of need

Example: An order for surgical dressings might specify one 4-inch x 4-inch hydrocolloid dressing which is changed one to two times per week for one month or until the ulcer heals.

For drugs:

• Name of the drug
• Concentration (if applicable)
• Dosage
• Frequency of administration
• Route of administration
• Duration of infusion (if applicable)
• NDC number if using a nonspecific code (e.g. J3490)

For orthoses:

If a custom-fabricated orthosis is ordered by the physician, this must be clearly indicated on the written order. If HMSA asks to see the order for a custom-fabricated orthosis and the order is not sufficiently specific, the claim may be denied or may be paid based on the eligible charge for a prefabricated orthosis.

Written Order Prior to Delivery

For the items listed below, the supplier must have received a written order that has been both signed and dated by the treating physician before dispensing the item. It is acceptable to submit a claim based on a photocopy, facsimile image or electronically maintained document.

Revision History