Durable Medical Equipment (DME) Durable Medical Equipment Provider Reference Manual Covered or Non-Covered DME Items The examples provided are not an all-inclusive list and are offered as a guide only. Refer to program requirements, coverage criteria, and the fee schedule for specific service information. Screening List for DME Nonstandard DME Request Process Coverage Guidelines for Durable Medical Equipment Activity Chairs Apnea Monitor Automatic External Defibrillator Breast Pumps Car Seats Commodes Compression Garments Continuous Passive Motion Devices (CPM) Cranial Remolding Orthosis Diapers/Underpads/Liners Dynamic Splinting Emergency Response Systems Enteral Nutrition and Total Parenteral Nutrition Gait Trainers Gloves Glucose Monitors Hearing Aids High Frequency Chest Wall Oscillation Device Home Infusion Therapy Infusion Pumps Hospital Beds Incontinence Appliances And Care Supplies Intermittent Positive Pressure Breathing System Lymphedema Pumps Minor Environmental Modifications Nebulizers/Supplies Negative Pressure Wound Therapy Orthopedic and Therapeutic Shoes Orthotic and Prosthetic Devices Osteogenesis Stimulator Ostomy Supplies Oximeters Oxygen And Oxygen Equipment Portable Oxygen Systems Patient Lifts Percussor Phototherapy Positive Pressure (PAP) Devices Power Operated Vehicle Pressure Reducing Support Surfaces Prone Standers, Supine Standers, Standing Tables Rollabout, Mobile Geriatric Chairs Seat Lift Chairs/Motorized Mechanisms Speech Generating Devices Suction Pumps Surgical Supplies Therapy Related Equipment Transcutaneous Electrical Nerve Stimulators (TENS) And Related Supplies Ventilators Walker Wheelchairs, Strollers Wigs DME- Special Medical Equipment, Home Modifications, and Minor Assistive Devices Prior Authorization Physicians writing scripts/prescriptions for durable medical equipment (i.e. diapers, nutrition, etc.) should give the script directly to the recipient and indicate to the recipient to contact a DME Supplier provider. The DME Supplier provider will initiate the prior authorization request with RI Medicaid. When prior authorization is required for a service, the DME Supplier provider is to submit a completed Prior Authorization Request form which can be obtained on the Prior Authorization page. This form must be signed and dated by the DME Supplier provider as to the accuracy of the service requested. Attached to this form will be the Proof of Medical Necessity signed by the prescribing provider. When necessary, further documentation should be attached to the Prior Authorization Request form to justify the request. Forms can be faxed to (401) 784-3892. Please note prior authorization requests for DME supplies received from a physician will be returned. Prior authorization does not guarantee payment. Payment is subject to all general conditions of RI Medicaid, including beneficiary eligibility, other insurance, and program restrictions. An approved prior authorization cannot be transferred from one vendor to another. If the beneficiary wishes to change vendors once the prior authorization has been approved, the new vendor will submit another Prior Authorization Request form with a letter from the beneficiary requesting the previous prior authorization be canceled. For those beneficiary’s dually enrolled in the RI Medicaid Program and Medicare, prior authorization is not required for Medicare covered DME services. Providers are required to accept Medicare assignment for all covered DME services. RI Medicaid will reimburse the copay and/or deductible as determined by Medicare up to the RI maximum allowable amount using the lesser of logic. Claim Preparation Instructions CMS 1500 Form Filing Instructions DME and Hearing Aids – CMS 1500 Claim Form Prior Authorization Forms - Certificate of Medical Necessity Error Status Codes ESC Code List (English) Explanation of Benefits (EOB) Codes EOB Codes and Messages List (English) EOB Codes and Messages List (Spanish) Appendix - Third Party Liability Carrier and Coverage Codes Third Party Liability Carrier and Coverage Codes For specific questions you may contact the Customer Service Help Desk at (401) 784-8100 for In-state and long distance callers, or 1-800-964-6211 for In-state toll callers and border communities.