DME, as defined by Original Medicare, is reusable medical equipment.¹

DME equipment under Medicare guidelines must meet these criteria²:

• Durable (can withstand repeated use)²
• Used for a medical reason²
• Typically only useful to someone who is sick or injured²
• Used in your home²
• Expected to last at least 3 years²

(Most private insurance companies follow Medicare guidelines. Please refer to your specific insurance plan for details.)

List of Medicare covered DME²

Medicare DME booklet¹

A durable medical supplier is any company selling medical equipment used in the home to aid in a better quality of living.

Durable medical suppliers offer DME equipment and medical supplies such as catheters, wheelchairs, shower chairs, canes, incontinence products, colostomy products, etc.

When you require a piece of DME equipment or specific medical supplies, you may have a choice of many different suppliers, but it is important to choose one that is in your insurer’s network (or participating in Medicare if applicable).^2,3

An EOB shows you your total charges for your visit. An EOB is not a bill. It helps you, the patient, understand how much your health plan covers, and what you’ll pay when you get a bill from your provider.⁴

The explanation of benefits includes information about:

• You (the patient)
• Your health plan
• Who provided your care and when it was approved
• A reference number called the claim number
• The person who gets reimbursed for overpayments called the payee⁴

Detailed explanation of how to read your EOB⁴

A standardized alphanumeric coding system used by medical providers to submit healthcare claims to Medicare and other health insurances.⁷

HCPCS Level I is comprised of Current Procedural Terminology (CPT), a 5-digit numeric coding system.⁷

CPT is a uniform coding system used by healthcare providers to describe the medical services they give—like checkups, treatments, or equipment. These labels help make sure insurance companies (like Medicare or private plans) know exactly what was done so they can pay the right amount.⁷

Definitions of HCPCS and CPT from the Centers for Medicare & Medicaid Services⁷

ICD-10 stands for the International Classification of Diseases, 10th Revision. It is a system used to code and classify diagnoses and procedures in healthcare.⁸

In the U.S., it includes:

• ICD-10-CM: for diagnosis coding in all healthcare settings⁸
• ICD-10-PCS: for inpatient procedure coding in hospitals⁸

Definition of ICD-10 from the Centers for Medicare & Medicaid Services⁸

A provider network is a list of healthcare providers who are contracted by an insurance company and provide medical care to those enrolled in plans offered by that insurance company.⁹

• The providers in the health insurance plans network are called “network providers.”
• Every insurance plan provides a list of in-network providers on their patient portals.⁹

A LOMN is a carefully written letter by your physician and/or physical therapist stating why the patient needs a specific piece of equipment, test, treatment, or medication.⁹

Your medical professional will diagnose your medical condition, include pertinent medical history, outline why that piece of durable medical equipment (DME) is medically necessary for your condition, even if your insurance provider deems certain DME as an accessory and not “medically necessary” under your insurance plan’s policy.^10,11

Full Definition of Medical Necessity¹¹

Medicare Part A refers to Hospital Insurance.¹²

It helps cover inpatient hospital care, skilled nursing facility care, hospice services, and some home health care. Most people receive Part A without paying a monthly premium if they or their spouse have sufficient work history (earned through Medicare‑covered employment and accumulated quarters of coverage).

Individuals who are already receiving Social Security or Railroad Retirement Board benefits are automatically enrolled at age 65, while others must apply through the Social Security Administration. Eligibility also extends to people under 65 with certain disabilities or End‑Stage Renal Disease.¹²

Detailed information about Medicare Part A¹²

Medicare Part B refers to Medical Insurance.¹²

It helps cover services such as doctor visits, outpatient care, preventive services, and medical supplies.

Unlike Part A, Part B requires a monthly premium for all beneficiaries, and individuals may face a late enrollment penalty if they do not sign up when first eligible. People who are already receiving Social Security or Railroad Retirement Board benefits are automatically enrolled, while others must enroll manually during an appropriate enrollment period.¹²

Detailed information about Medicare Part B¹²

Medicare Part C, also called Medicare Advantage, is an alternative way to receive Medicare coverage through private companies approved by Medicare.¹³

These plans provide all Part A (Hospital Insurance) and Part B (Medical Insurance) benefits and may also offer additional coverage such as vision, hearing, dental, and wellness programs. Most Medicare Advantage plans include prescription drug coverage (Part D).

Medicare pays a fixed monthly amount to the companies offering these plans, and while they must follow Medicare rules, each plan may have different out‑of‑pocket costs and service requirements, including whether referrals are needed or whether members must use in‑network providers.¹³

Detailed information about Medicare Advantage Plans (Part C)¹³

Medicare Part D refers to Medicare drug coverage.¹⁴

It helps pay for the brand‑name and generic prescription medications you need. Part D is optional and is offered through private insurance companies approved by Medicare. Even if you are not currently taking prescription drugs, enrolling when you first become eligible is encouraged to avoid a late enrollment penalty if you join a plan later.¹⁴

Detailed information about Medicare Part D¹⁴

A provider who is not contracted with your insurance company for reimbursement at a negotiated rate.

If you see an out-ofnetwork provider, or a provider that is not in your insurer’s network, you may be responsible for a higher co-pay, deductible, and out-of-pocket limit. Seeing a provider outside of your network may significantly increase your costs.⁹

Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.¹⁵

Full Definition Prior Authorization¹⁵