Ordering medical supplies through Medicare involves navigating specific administrative and medical requirements to ensure coverage for equipment needed to manage a health condition at home. This process requires coordination between the beneficiary, the treating physician, and a Medicare-approved supplier. Coverage is not automatic, and proper documentation is necessary at every stage to avoid unexpected costs or delays in receiving equipment. The system provides coverage for items that meet a defined standard of medical necessity for use outside of an institutional setting.
Establishing Medical Necessity and Coverage
Medicare generally covers Durable Medical Equipment (DME) under Part B, which includes reusable items like wheelchairs, oxygen equipment, and hospital beds that are used within the home. To qualify for coverage, the equipment must be deemed medically necessary by a treating physician, meaning it is required to treat an illness, injury, or diagnosed condition.
The initial step is obtaining a detailed written order from the physician or another approved practitioner. This order must be completed before Medicare can process a claim. For certain specified items, the treating practitioner must have conducted a face-to-face examination with the beneficiary within six months before the order date to verify the medical need.
The written order itself must include the beneficiary’s name, a detailed description of the item, the quantity needed, the date of the order, and the prescribing practitioner’s signature and National Provider Identifier (NPI). This documentation must clearly substantiate the medical need for the item by referencing the beneficiary’s diagnosis, the duration of the condition, and any functional limitations. Medicare defines DME as equipment that can withstand repeated use, is primarily for a medical purpose, is not generally useful to a person without illness or injury, and is appropriate for home use.
Selecting Suppliers and Submitting the Order
Once medical necessity is established, the next step is selecting a supplier that is enrolled in Medicare and accepts “assignment.” Choosing a supplier who participates in Medicare is important for managing costs. Suppliers who accept assignment agree to accept the Medicare-approved amount as full payment for the item, which limits the amount they can charge the beneficiary.
Beneficiaries can find approved suppliers by using the Medicare Supplier Directory or by calling 1-800-MEDICARE. Using a non-participating supplier who does not accept assignment can result in significantly higher out-of-pocket costs because they are not bound by the Medicare-approved rate.
After selecting an approved supplier, they will work with the physician to assemble the documentation packet, which may include a Certificate of Medical Necessity (CMN) for certain items. The CMN, along with the detailed written order and supporting medical records, formally justifies the request to Medicare. The supplier is responsible for submitting the claim to Medicare, along with proof of delivery, which includes the beneficiary’s signature and the date the item was received. The supplier must also maintain records of the face-to-face examination and the written order to make them available to Medicare upon request.
Understanding Financial Responsibility
Even with Medicare coverage, the beneficiary retains financial responsibility for a portion of the cost of the medical supplies. Durable Medical Equipment is covered under Part B, which means the annual Part B deductible must be met before Medicare begins to pay. After the deductible is satisfied, the standard cost-sharing model requires the beneficiary to pay 20% of the Medicare-approved amount, known as coinsurance. Medicare pays the remaining 80% of the approved amount to the supplier.
The determination of whether an item is purchased or rented also impacts the financial structure. For certain expensive equipment, like standard wheelchairs or hospital beds, Medicare pays to rent the item for 13 months, after which ownership is transferred to the beneficiary. For items like oxygen equipment, monthly rental payments continue for 36 months, with the supplier remaining responsible for maintenance for a total of five years, as long as medical necessity continues. If a supplier does not accept assignment, they can charge more than the Medicare-approved amount, leaving the beneficiary responsible for the 20% coinsurance plus the entire excess charge.
What to Do If Your Claim Is Denied
A denial of a claim for medical supplies is often due to missing or insufficient documentation, such as a lack of a clear medical necessity statement or an invalid written order. If a claim is denied, the first formal step in the appeals process is to request a Redetermination, which is a re-examination of the initial decision by the Medicare Administrative Contractor (MAC). The beneficiary or their representative must submit this request in writing within 120 days of receiving the initial denial notice.
The Redetermination request should clearly state why the beneficiary disagrees with the initial decision and include any new medical evidence or documentation that supports the claim. The MAC generally has 60 days to complete this review and issue a decision. If the Redetermination is unsuccessful, the beneficiary can then proceed to the second level of appeal, which is a Reconsideration by a Qualified Independent Contractor (QIC). Following the established five-level appeal hierarchy ensures that beneficiaries can systematically challenge coverage decisions.