durable medical equipment (DME) capped rental payment policy
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durable medical equipment (DME)
capped rental payment policy
description of procedure/service
This policy applies to the payment for capped rental DME when authorized by FCHP and
provided by a FCHP contracted DME provider.
Unless stated differently in a provider's contract, Fallon Community Health Plan will pay a
provider for 10 months of the contracted rental allowable up to the applicable DME limit. After
10 months, the member owns the equipment. Once the member owns the equipment, the
regular DME rules for maintenance and repair apply.
5 FCHP Direct Care/FCHP Select Care
5 FCHP Independent Care
5 FCHP Flex Care Direct/Select
5 Fallon Senior Plan™
5 FCHP MassHealth
5 Major Medical
5 Bill at Home/Direct Enrollment
Fallon Preferred Care
coverage and reimbursement criteria
Unless stated differently in a provider’s contract, Fallon Community Health Plan will reimburse
for capped rental DME for 10 months as described above.
If the 10-month period is interrupted by an inpatient skilled nursing facility or hospital admission
which exceeds 30 days, the 10-month rental clock is paused. During the interruption time, all
rental payments stop. When the patient begins using the equipment again, the rental clock is
restarted and continues from where it had previously stopped. If the interruption is longer than
60 days plus the leftover days in the interrupted month, the rental clock is stopped completely
and must start over. When this occurs, a new prescription for the equipment and proof of
medical necessity may be required.
If a member changes DME providers, the rental clock does not restart. Likewise, a minor
change with the DME equipment does not cause the rental clock to restart. If FCHP determines
that a "substantial change" in DME equipment has occurred, the rental clock is restarted and a
new 10-month period begins. Determination of “substantial change” is