Required Documentation to Have Home Medical Equipment Covered by Insurance

by Medical XPress

Health insurance form stamped with APPROVED in greenIf you require durable medical equipment (DME) for use in your home, you’re likely looking for ways to offset the total cost. After all, DME can often run in the thousands for a single piece of equipment, depending on what you’re looking for. That’s a cost that most individuals can’t afford to tackle on their own. The good news is, when it comes to DME, insurance may be able to help; you’ll just need to make sure you have the proper documentation to file your claim.

Prescription from Your Primary Physician

The number-one piece of documentation (and sometimes the only one) you’ll need is a prescription from your doctor. They must fill out a formal prescription on a standard prescription pad, stating that the equipment is required for treatment of or to improve quality of life while living with your condition. Many patients may overlook this step, because you can purchase most DME without a prescription. (The one notable exception to this is medical oxygen.) But, while you can purchase the DME without a prescription, you don’t have much chance of having your insurance cover the equipment if you don’t get a prescription.

With this in hand, one of our medical supply store representatives can help you find the exact equipment you need, that falls within the parameters of your prescription, so you can file a claim with your health insurance provider.

Justification Statement of Medical Necessity

As an alternative to a prescription—or perhaps in addition to one—a physician or therapist may be able to supply their insurance company with a Justification Statement of Medical Necessity. This is a formal letter that addresses the following issues:

  • Why the equipment is medically necessary
  • Why an off-the-shelf alternative is not sufficient for your needs
  • How this piece of equipment meets your needs
  • How the equipment will reduce your symptoms or otherwise improve your condition
  • How the equipment will improve your capacity for normal activity

This letter should focus heavily on medical information and the medical necessity of the equipment. It should avoid mention of any social, psychosocial, or leisure benefits. If the letter is coming from a therapist, it should be accompanied by a letter from your primary care physician; your physician may also write a short concurrence statement at the end of the therapist’s letter, essentially stating that they agree the equipment is a medical necessity.

Qualified Supplier List

While this isn’t a piece of documentation you need to provide, it is something that you need to review to ensure that your medical insurance provider will help cover the cost of your DME. Most providers have a network of qualified DME suppliers, just as they will have in-network service providers. You should ensure that the location you choose to buy from is covered by your insurance. The best way to do this is to simply ask your insurance provider which suppliers are in their network; there is often an online tool to help you do this.

Please note that this requirement also applies to Medicare. While DME is almost always covered by Medicare (at least partially, if not fully), they do have a very specific list of qualified Medicare DME suppliers. If you purchase DME outside of this list, Medicare will not cover it.

Get Help Navigating Your Insurance Claim

We understand how difficult it can be to navigate the complexities of health insurance coverage, especially for purchasing in-home medical equipment. At Medical Xpress and Arlington Medical Supply, we’re happy to help our patients ensure that they have the right prescription for the equipment they’re purchasing, and provide them with advice on how to submit an insurance claim.

We also strongly encourage you to speak to your insurance provider about how to file this type of claim. Please keep in mind that all insurance providers’ requirements can vary, and yours might require an additional type of documentation not listed above. Always do your research, ask questions, and gather all the documentation you need before making a purchase of any DME. This is the best way to ensure that your medical insurance provider will help to offset the costs of this equipment.

If you have questions about any of the DME we carry at our locations, we invite you to reach out to us today.