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DME guidance for the provider

A detailed written order is needed to request durable medical equipment (DME) for an injured worker.
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A detailed written order is needed to request durable medical equipment (DME) for an injured worker. The prescribing physician, nurse practitioner or physician assistant should review the content and sign and date the order. The order will be sent to the DMEPOS vendor. The vendor should dispense the device or item as written on the script. 

If the request is incomplete or unclear on the specific item being requested, the DMEPOS vendor should contact the referring provider to supply the missing information prior to filling the order. 

The following information should be included on the request: 

  • Name of injured worker, claim number and date of the order 
  • Printed name and signature of the physician or practitioner 
  • HCPCS code, modifier, and description of the items, accessories and features 
  • Diagnosis and medical necessity 
  • Frequency and duration of use and specify rental versus purchase 

Authorizations 

There are treatments and devices that do not require prior authorization for payment because they are within the Medical Treatment Guidelines, DOWC Rule 17 and exhibits. However, other devices not addressed in the guidelines need prior authorization before the item is furnished or a bill is submitted. Any request for prior authorization must be clearly labeled as such per Rule 16. 

The documentation should include: 

  • An adequate definition or description of the nature, extent and necessity for the device, 
  • Identification of the appropriate Medical Treatment Guideline, if applicable, 
  • Additional accessories and upgrades described with a HCPCS code and a general description with a brand name /model number, and 
  • Final diagnosis.

Billing 

Providers that supply and bill for DME will use a nationally recognized HCPCS or CPT code and modifier when one exists, and reimbursement is based on Medicare’s HCPCS Level II codes

For unspecified items and HCPCS codes without a fee schedule, the provider should submit a detailed description of the service or equipment with the bill. Reimbursement is based on the cost to the provider of the dispensed item as indicated by the manufacturer’s actual invoice. 

  • Altered, edited, or handwritten invoices should not be used to substantiate the cost. 
  • The invoice date should be within twelve months from the date the device is provided to the injured worker. 
  • The invoice item description should match the billed item on the claim. 

This document is for informational purposes only and is not intended in any way to dictate the type or duration of medical treatment prescribed. Providers must exercise independent medical judgment in prescribing treatment.

Per Rule 16, an injured worker shall never be required to pay directly for admitted or ordered medical benefits covered under the Workers’ Compensation Act. No financial arrangements should be made to charge an injured worker or advance the cost of DME. 

For questions, please contact billingsuccess@pinnacol.com. 


Please view the PDF for a flowchart of the referral and prior authorization process.

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