Get the free Durable Medical Equipment and Medical Supply Claim Form

This form is used by members of Regence BlueCross BlueShield of Oregon to request reimbursement for medical equipment and supplies. It includes sections for patient and subscriber information, receipt

How to fill out durable medical equipment and

How to fill out Durable Medical Equipment and Medical Supply Claim Form

1. Begin by obtaining the Durable Medical Equipment and Medical Supply Claim Form from the provider or online.
2. Fill in the patient's information including name, address, and insurance details.
3. Provide the healthcare provider's information, including NPI number and contact details.
4. List the Durable Medical Equipment and/or medical supplies being claimed, including item descriptions and HCPCS codes.
5. Indicate the quantity of each item being claimed.
6. Fill in the date of service for each item listed.
7. Include the total charges for the equipment and supplies.
8. Sign and date the form at the bottom, confirming the accuracy of the provided information.
9. Submit the completed form to the appropriate insurance company or payer.

Who needs Durable Medical Equipment and Medical Supply Claim Form?

1. Individuals who require assistive devices for medical conditions or disabilities.
2. Patients recovering from surgery who need medical supplies.
3. Caregivers managing home healthcare for patients requiring specialized equipment.
4. Healthcare providers submitting claims on behalf of patients for insurance reimbursement.

People Also Ask about

What is the UB04 form used for?

The supplier should bill the date of service on the claim as the date of discharge and shall use the place of service (POS) as 12 (patient's home). The item must be for subsequent use in the patient's home.

How to submit DME claims?

Step 1 – DME MAC Jurisdiction. Determine your Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) from the. STEP 2 – Complete the CMS 1500-Claim Form or send the medical claim electronically* STEP 3 – Find medical billing and claim submission information from your Jurisdiction.

What is the CMS 1500 claim form used for?

The UB-04 claim form is used to submit claims for outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics and chronic dialysis centers).

What is a letter of medical necessity for durable medical equipment?

A Letter of Medical Necessity (LMN) is the written explanation from the treating physician describing the medical need for services, equipment, or supplies to assist the claimant in the treatment, care, or relief of their accepted work-related illness(es).

What is a 1490 form?

CMS 1490S. Form Title. PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)

What claim form is used for DME?

CMS-1500 Claim Form Instructions - JD DME.

What is the difference between medical supplies and durable medical equipment?

To qualify as DME under Medicare, a piece of equipment or device must have an expected lifespan of about 3 years with repeated home use and serve a strictly medical purpose. Expendable medical supplies such as bandages, masks, and rubber gloves are not considered DME under Medicare.

For pdfFiller’s FAQs

What is Durable Medical Equipment and Medical Supply Claim Form?

The Durable Medical Equipment and Medical Supply Claim Form is a document used to request reimbursement for medical equipment and supplies that are considered necessary for a patient's care and treatment.

Who is required to file Durable Medical Equipment and Medical Supply Claim Form?

Healthcare providers, such as physicians, suppliers of durable medical equipment, or facilities that provide medical supplies, are required to file this form on behalf of patients to seek reimbursement from insurance companies.

How to fill out Durable Medical Equipment and Medical Supply Claim Form?

To fill out the form, providers must enter patient information, details about the equipment or supplies being billed, billing codes, dates of service, and sign to certify the information is accurate and complete.

What is the purpose of Durable Medical Equipment and Medical Supply Claim Form?

The purpose of the form is to facilitate the reimbursement process for medical supplies and equipment deemed medically necessary for patient care and ensure that the billing is processed correctly by insurance companies.

What information must be reported on Durable Medical Equipment and Medical Supply Claim Form?

Required information includes patient details (name, address, insurance information), provider information, item descriptions, quantity and cost of equipment/supplies, billing codes (such as HCPCS), and dates of service.