Humana Claim Payment Policy Update

December 2018 ~

Humana has published a new claim payment policy update for durable medical equipment (DME) repair and replacement.

The following update establishes how Humana plans reimburse the repair and replacement of DME base items, parts and accessories.

Medicare Advantage and Commercial Payment Policy

Replacement of a DME base item, part or accessory may be reimbursed after the standard reasonable useful lifetime (RUL) of five years if it is still medically necessary but no longer functional. The RUL period begins the first date of service when the specific base item, part or accessory was individually reimbursed.

Repair or replacement of a DME base item, part or accessory is not reimbursed, in any event, while under a manufacturer’s or supplier’s warranty or during a rental period of the item.

Replacement of a DME base item may be reimbursed before expiration of the RUL only if either:

• The member’s medical needs have changed such that a different item is medically necessary; or
• Both the item was lost, stolen or unintentionally and irreparably damaged, and the member’s plan’s certificate does not exclude coverage of replacement in such a scenario.

Modifier RA must be billed with the Healthcare Common Procedure Coding System (HCPCS) code for that replaced base item.

Replacement of a part or accessory to repair a base item, due to unintentional damage or normal wear, may be reimbursed before the expiration of the RUL of the part or accessory, only when both replacement was necessary to make the base item functional and the part or accessory is not covered under a manufacturer’s or supplier’s warranty. Documentation of an expired or denied warranty is required, upon request. Modifier RB must be billed with the HCPCS code for that replaced part or accessory.

A charge for a part or accessory is not reimbursed for a member unless the base item is owned by the same member.

Reimbursement for repair, including labor and parts, of a DME item is limited to the purchase price of that item.

Repair, including labor and parts, of oxygen equipment and of DME items in the frequent and substantial servicing category is not reimbursed.

Source(s): Humana;