Insurance Reimbursement

Ok, I am starting to get to be an old hand at this and I thought I would give a how to on it.


First things first! If this doesn't work, I am not paying for your equipment! I am only relating what worked for me, your mileage may vary.


A lot of folks seem to be of the opinion that if you buy online you won't/can't get insurance reimbursement. This was not the case for me, BUT you have to check with your specific insurance on the billing codes listed below.

I can not emphasize this enough, you need the billing codes!! (sometimes referred to as HCPCS codes) The insurance companies do not know a BIPAP from a BIPLANE! They know billing codes, and they know how much each code can reimburse.

Once you have established that your insurance company will reimburse you (I suggest getting a name of a person, in case you get an argument later)
get their latest claim form, (ask them to email, mail or fax it to you, if you don't use the latest form, your claim can and more than likely will be denied) and fill the form out in its entirety.

Now, on your receipt from your online vendor you might see a column called billing codes, https://www.cpap.com includes these and nothing further is required. HOWEVER, if you do not have the codes, DO NOT send the receipt without them. You will either a) get denied straight off, or it will go to a claims specialist that will promptly lose it. In other words, don't do it. Did I mention not to send it without codes? GOOD.

Here are some common codes:


E0601 CPAP (there is NO APAP CODE USE THIS FOR APAP!)
K0532 BiPAP

K0268 Humidifier, cool
K0531 Humidifier, heated

A7030 Full Face Mask ea.
A7031 Full Face Mask Interface, Replacement
A7032 Replacement cushion for nasal applications
A7033 Nasal appliances - pillows, seal, replacement parts
A0734 Nasal Interface - mask, cannula ea.
A7035 Headgear
A7036 Chinstrap
A7037 Tubing
A7038 Filter, Disposable
A7039 Filter Non-Disposable
A7044 Oral Interface ea.


One of the things that my insurance company does (Anthem) is to send the claim to the state in which the company is located. This unfortunately does cause a delay. In Anthem's case if they receive no response after 21 days, they pay the claim locally.

The only other suggestion that I can give is be persistent. Keep calling and take names. If you jump through all of their hoops, you will eventually get your reimbursement.

I finally got my last check this week. My copay for a Remstar Auto with Cflex with the heated humidifier was $202. (20% copay) $27.80 for a Ultra Mirage Full Face Mask. And I paid out of pocket for the Encore Software. Total with the software was under $500 out of pocket. Much less than the local DME wanted for bottom of the line equipment.

Miko! This seems like it would make a great CPAPopedia entry. Mind if I use it?

Sure!!

I also got reimbursed from my insurance company. Along with the claim, I sent a letter. My local DME did not have a machine with the capabilities I needed (ability to run on different power, as I occassionally travel out of the country, and I camp every summer) - or at least said they could not supply me with one. Since I HAD to have something that would use more than just 110 power, I purchased on line. I submitted the bill along with a letter, where I explained that the DME was unable to supply the machine I needed, and explained why I needed a machine with other power capability. I also listed all the costs of getting the equipment from the DME (the DME cost to rent times the months needed before I owned, mask, humidifier, etc.) and showed that the DME cost was actually more than I had paid. I actually got a phone call from the insurance claim manager. She was quite impressed by the difference in price. She had never heard of people buying equipment on line, so I gave her the web address of several online suppliers, and explained how easy and convenient it was, and how helpful I had found the on line suppliers. I got the reimbursement with no delay or problem.
Debbie

That brings up a good point Deb. With the claim for your machine quite often you will have to provide:

RX for CPAP (it does NOT have to say APAP, remember Bipap, Biplane?)

Letter of medical necessity. I used my sleep study that had a summary page from the sleep doc specifying the necessity for CPAP.

Compliance info. I have heard that some insurance companies will take your word for it if you write them a letter. As I have the software for my machine, I simply printed out the compliance report.

Ironically, I was paid for the mask without any of the above... Not sure what they thought I was going to a mask without a machine, but again it goes back to the billing codes.

Thanks for the translations. Being able to speak the language they understand is definately helpful when trying to communicate with them..

Here is anouther IMPORTANT point about filing a claim. Always provide a diagnosis code. For obstructive sleep apnea, it is 780.53. For most insurance companies, you will not get paid without it.

That was included in my letter of medical necessity but not on my claim form. But good info.