Billing

1. Use the 837P professional claim format.
2. Report the name and National Provider Identifier (NPI) number of the actively enrolled ordering provider in the “Other Provider Types” section of the 837P professional claim format.
3. Use current Healthcare Common Procedure Coding System (HCPCS) procedure codes and modifiers.
4. Providers must enter the following modifiers as appropriate for all equipment or supplies covered under a waiver. The modifier will not be included on the Service Authorization.
   1. NU = New – when purchasing new equipment or supplies
   2. UE = Used – when purchasing used equipment or supplies
   3. RR = Rental of equipment or supplies
   4. RB = Repair of an item or part
5. To determine the appropriate HCPCS code to use with a covered service, access the Medicare Pricing, Data Analysis, and Coding (PDAC) Product Classification List website.
6. Use a modifier to indicate purchase, rental, repair, or replacement of part. Additional modifiers may be appropriate depending on the item or service.
   1. For capped rental items that are billed as rental, use modifier KH for the first month, KI for the second and third months, and KJ for months 4 – 15 of rental. PrimeWest Health will reimburse for modifiers KH and KI at 100 percent of the Minnesota Health Care Programs (MHCP) fee schedule monthly rental rate and modifier KJ at 75 percent of the MHCP fee schedule monthly rental rate. Modifiers KH, KI, and KJ also apply to any authorization request for a capped rental item. Each K modifier must be on a separate line on the authorization request.
   2. Rentals will only be paid up to the allowable amount.
7. The cost of shipping, handling, or freight charges are all-inclusive in the PrimeWest Health payment rate and are not reimbursable. If these charges are included on the invoice or as part of the manufacturer’s suggested retail price (MSRP), they will be excluded from the payment.
8. Follow Medicare guidelines for when to use modifiers AU, AV, AW, KC, KE, KL, KM, and KN. When billing for these modifiers, providers must also include modifier NU to be reimbursed at the appropriate Medicare rate. Do not bill setup, pickup, or delivery expenses—the cost of delivery is included in the rental or purchase payment.
9. Do not bill for service calls that do not involve actual labor time for repairs.
10. Reimbursement for all rental items will cap at the Medicare purchase rate or the MHCP maximum allowed payment rate when renting any equipment. Do not continue to bill monthly rental after the maximum rate has been reached. Apply full rental payments (including all payments received from primary third party payers) to all purchases. After PrimeWest Health purchases the medical equipment or supply for a recipient, the item is the recipient's property.
11. For equipment or medical supply item that requires manual pricing or is not listed on the Minnesota Health Care Programs (MHCP) Fee Schedule, attach the manufacturer’s invoice/price list to the claim.
12. Clearly indicate which item on the documentation corresponds to each item on the claim.
13. Do not modify, alter, or change the price list or invoice.
14. Do not block out any information on the invoice/price list.
15. If the manufacturer’s invoice/price list is not available, submit a quote from the manufacturer, dated no earlier than three months before the DOS and no later than the DOS.
16. If authorization is required, the claim must match HCPCS code, modifiers, and description/model number as noted on the authorization letter. Report the description/model number in the Model Number field in the “DME Information” section of the Services tab. When the Model Number field is used, do not use the “Notes” field on the Services tab. Use the “Claim Notes” field on the Claim Information tab. Enter the line item number and then the text or narrative that is required.
17. Do not bill for sales tax. DME items are exempt from sales tax for the State of Minnesota. Refer to the Minnesota Department of Revenue’s Durable Medical Equipment Sales Tax Fact Sheet 117B for additional information.

Third Party Liability (TPL) and Medicare

Providers must meet any provider criteria, including accreditation and surety bond requirements, for third-party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.

1. Providers who cannot receive Medicare payment for the service must refer and document the referral of dual-eligible members to Medicare providers when Medicare is determined to be the appropriate payer.
2. Providers who cannot receive TPL payment for the service must refer members to TPL providers.
3. Providers who do not meet provider requirements for the primary payer will not be reimbursed by MHCP.

MHCP quantity limits and thresholds apply to all members unless only Medicare co-insurance or deductible is requested.

Billing Miscellaneous and Manually Priced HCPCS Codes

1. Do not use miscellaneous codes when a more appropriate code is available.
2. A Manufacturer’s Suggested Retail Price (MSRP) document from the manufacturer is required. If MSRP is not available, PrimeWest Health will accept an invoice from the manufacturer.
3. Submit the pricing document as an attachment as described in Claims Submission.
4. Items included on an approved authorization have already been priced and do not require manual pricing of claims.
5. Clearly indicate which item on the pricing documentation corresponds to each item on the claim.
6. Do not block out or modify the price list or invoice (you may star or circle).

Dispensing of Equipment/Supplies 

1. Dispense no more than one month of supplies at a time unless specifically permitted by coverage policy.
2. Requests must come from the member or an authorized representative each time additional supplies are needed.
3. It is acceptable for medical supply providers to call the member to verify a re-order.
4. Automatically shipping supplies without an indication from the member or the member’s authorized representative confirmation is not permitted.

PW_11-19_540
Updated_12/09/2022