Photo of patient being fitted for a CPAP mask

Referrals

Your referral is appreciated and Ridgeview can assist you with this process. You can contact Ridgeview Home Medical Equipment directly at 952-442-2283 during business hours and staff will support you through the process. Additionally, you can send your prescription via fax to 952-241-1342 or email to hme@ridgeviewmedical.org

The process

Durable Medical Equipment (DME) coverage is often a component of your insurance that flies under the radar. The good news is that there is usually coverage, but obtaining coverage while meeting requirements can be difficult to navigate.

Ultimately, Ridgeview can and will assist you in understanding the requirements your insurance asks. You are encouraged to contact your insurance as well.

Depending on your insurance, and your desired involvement from the insurance, there are a few things to consider:

  • In order to bill items to your insurance, a prescription is needed.
  • Please keep in mind, not all items are billable to insurance and even if you have a prescription for the item, your insurance policy may determine that the items are not eligible for insurance billing.
  • Certain items, again depending on insurance, require a face-to-face visit with your physician prior to obtaining the items.
  • It is very important, especially for items that require a face-to-face visit, your physician dictates and documents your need for the medical equipment in your chart.
  • In many instances, insurances will request this documentation from us and if we are not able to obtain, or the medical records do not reflect the need for the equipment, we are unable to provide the equipment until we have satisfied this requirement.
  • Again, the prescription is often times the very start of the process and should be accompanied by comprehensive chart notes from your physician or medical professional.
  • Certain items, oxygen for example, require annual visits to your physician for ongoing coverage. These visits should yield a new prescription along with comprehensive chart notes.

Billing your insurance and Durable Medical Equipment (DME)

Ridgeview Home Medical will bill your insurance for your supply and equipment needs. It is very important that you understand your coverage as well.

DME is unique to other services that are billed to your insurance in that many of the products are required by insurances to be billed as rental items. This means that your equipment will be billed to your insurance, usually at monthly intervals, for the period of time dictated by your insurance. After that period of time, you own the equipment and your insurance will no longer be billed.

Coverage determination and Estimates

Ridgeview Home Medical will provide estimated out-of-pocket expenses. It is important for you to know some key words when trying to understand your insurance:

  • Deductible
  • Out of Pocket Max
  • Coinsurance

Coverage determination and estimates

Ridgeview Home Medical Equipment is able to provide estimated out-of-pocket expenses. It is important for you to know some key words when trying to understand your insurance:

Deductible – is the amount you pay each year for covered health care service(s) before your health plan/insurance begins to pay. The deductible is paid to the provider – this is separate from the premium(s) paid to the insurance company.

Coinsurance – is the amount you pay for covered health care service(s) after you meet your deductible. This amount is a percentage of the total cost of care/service(s). For example, If you have a 20 percent coinsurance – your insurance provider will pay 80 percent of the claim to the provider and you are responsible for 20 percent.

Out of Pocket Max – Once you have met your deductible and coinsurance amount, you will hit your Out of Pocket Max and now insurance will pay the provider in full and no out of pocket expenses should be incurred.

Charge Amount vs. Allowed Amount – Charge Amount is the amount Ridgeview (the provider) submits to your insurance company. An Allowed Amount is an approved dollar amount that a health insurance company will reimburse a provider for a certain medical expense. The dollar difference between Charge Amount and Allowed Amount is usually adjusted off by the provider and not passed on to the patient.

Covered Service(s) – means the supplies and equipment for which coverage benefits are available under the health care plan. Covered services means beneficiaries are given benefits according to the terms and conditions of health plans – all deductible & coinsurance requirements apply. You may be responsible for all or a portion of the insurance allowable charges for supplies and equipment.

Initial and ongoing Prior Authorizations

For certain equipment, Ridgeview is required to gather clinical documentation to obtain an initial Prior Authorization or PA.

After receiving the initial PA, specifically with product groups like CPAP, Ridgeview is required to obtain ongoing PA’s for continued coverage. Insurances requiring ongoing PA’s in regard to CPAP are focused on obtaining compliance data indicating that you are using and benefitting from your device.

Ridgeview can walk you through the process to ensure you’re able to utilize your insurance benefits to their fullest.