Categories and Questions  Categories Only

Medicare
Private Insurance
	Introduction
		What will I learn from an insurance verification?
		Will I have a payment at the time of shipping?
		What does "In Network" mean?
		What does private insurance cover?
		What does "Out of Network" mean?
		Can I find out what my insurance plan covers on my own?
		Will my insurance cover the cost of software and DC power equipment?
		If I call you with my plan name, can you tell me what my co-pay will be?
		Am I obligated to go to receive equipment if I complete the form?
	"In Network" Insurance Companies
		Blue Cross Blue Shield
		No Questions Available
Our Company

Overview

Medicare covers a wide range of products that assist in the treatment of Sleep Apnea.

Medicare sets a range of fees for each item or service it covers. Each state sets it's own fee level within the range set by Medicare. Medicare pays 80% of that fee. Medicare covers the capped rental of CPAP or BiPAP equipment, as well as authorized CPAP supplies.

Payment of the remaining 20% not covered by Medicare, (referred to as a co-pay) is the responsibility of the patient or their secondary insurance carrier. The 20% co-payment is billed to the secondary insurance, or the beneficiary, only after Medicare has paid their portion of the fee. No money is collected at the time of shipping.

If you receive equipment from our company neither you for nor Medicare will be charged a shipping fee.

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Machines

CPAP, APAP or BiPAP machines are purchased via a 13 month capped rental process during which Medicare is billed at a monthly rental rate. After 13 months of rental the machine will converted to a purchase. The machine becomes the property of the patient.

Medicare guidelines do not allow for the direct purchase of CPAP, APAP or BiPAP machines. The machines themselves must go through a rental process that leads to the beneficiary owning the machine. This process is referred to as a capped rental. Medicare will covers 80% of the rental cost of CPAP, APAP or BiPAP Machines. Medicare itself sets the amount billed each month.

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Supplies

Medicare understands the need to replace the supplies required to successfully recieve your Sleep Therapy. Medicare covers 80% of fee set by Medicare itself. Medicare sets an eligibility span for each item covered.

CPAP supplies covered by Medicare include the mask and headgear, nasal pillows, tubing to deliver the air, disposable and washable filters, and humidifier chambers.

Medicare provides guidelines for beneficiary receipt of CPAP and Sleep Apnea related equipment. This means that you can be regularly provided you with brand new CPAP equipment through our services. Here is a quick reference chart of supplies and their allowed rates of re-order:

HCPCS Code	Description	Allowed Replacement Frequency
A7030NU	Full Face Mask	1 every 90 days
A7031NU	Full Face Cushion	1 every 30 days
A7034NU	Nasal Mask	1 every 90 days
A7045	Exhalation Port with or without Whisper Swivel	Span Not Yet Released By Medicare
A7032NU	Nasal Mask Cushion	2 every 30 days
A7044NU	Oracle	1 every 90 days
A7033NU	Nasal Pillows	2 pairs every 30 days
A7035NU	Headgear	1 every 180 days
A7036NU	Chinstrap	1 every 180 days
A7037NU	Tubing	1 every 90 days
A7039NU	Non-Disposable Filters	1 every 180 days
A7038NU	Disposable Filters	2 every 30 days
A7046	Humidifer Chamber	1 / 6 months
E0601NU	CPAP	1 every 5 years, with valid medical need
E0470NU	BiPAP	1 every 5 years, with valid medical need
E0562NU	Heated Humidifier	1 every 5 years, with valid medical need
E0561NU	Passover Humidifier	1 every 5 years, with valid medical need

Medicare does not cover accessories. Examples of accessories are non-essential items such as Hose insulators, software and card readers and battery packs. This type of item can be self purchased.

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Deductible

The 2008 Medicare deductible is $135.00. All Medicare beneficiaries have to meet this deductible. Payment of the $135.00 deductible amount is the responsibility of the patient. Some insurances that are secondary to Medicare pick up the yearly deductilbe.

By Medicare guidelines, the deductible can not be waived, nor negotiated.

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#1 Verify Your Insurance Coverage

Patient Information

• Full Name
• Phone Number
• Social Security Number
• Date of Birth
• Mailing Address Medicare Has On File

Medicare Information

• Do you currently own CPAP equipment?
• Do you currently have CPAP equipment on rental/maintenance with another provider? If so, which provider?
• Have you received CPAP equipment or supplies in the last 180 days?
• Medicare Number
• Social Security Number
• Physician Information
  • Name
  • Phone
  • Fax
  • Address
  • UPIN
  • NPI

  Payment Information

  • Secondary Insurance (If Applicable)
    • Name
    • Insurance ID
    • Insurance Group Number
    • Insurance Address
    • Policy Holder Name

    
    
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    #2 Obtain A Valid Sleep Study

    What is this?

    When a doctor suspects a patient has OSA (Obstructive Sleep Apnea), the next step is to confirm the diagnosis and establish the severity of the OSA. The process usually involves an overnight visit to a Sleep Clinic or Sleep Center where the patient is monitored and recorded.
    
    An Attended Polysomnogram Study is performed in a Sleep Center. It establishes the presence of Sleep Apnea and determines the severity of OSA. The study is used by Medicare and private insurance companies to determine if a patient has severe enough OSA to qualify for coverage. The Sleep Study must be conducted in an attended, permanent facility.
    
    A Titration sleep study is used to determine the optimum pressure required to maintain a patient's airway during sleep.

    How Recent Must It Be?

    Sleep studies do not expire. As long as your study meets the requirements discussed below and a copy can be obtained it is valid.

    Components

    Before we can dispense equipment our patient must have visited an attended sleep lab facility and been diagnosed with Obstructive Sleep Apnea (OSA).
    
    To receive equipment under Medicare, a patient's Sleep Study results must meet one of the following sets of requirements:

    • The apnea hypopnea index (AHI) must be greater than or equal to 15 events per hour
      • Data must be explicitly stated, not extrapolated.

      The diagnostic portion of the sleep study must be 2 hours or longer in duration.

    • The diagnostic portion of the sleep study must be performed in an attended sleep lab facility.

    -OR-

    • The AHI must be from 5 to 14 events per hour with documented symptoms of:
      • Hypertension, history of stroke or ischemia heart disease.
      • Excessive daytime sleepiness, impaired cognition, mood disorders or insomnia.

      The diagnostic portion of the sleep study must be 2 hours or longer in duration.

    • The diagnostic portion of the sleep study must be performed in an attended sleep lab facility.

    Medicare is not flexible with these requirements and by law we may not vend equipment to Medicare patients who do not meet these guidelines.

    
    
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    #3 Obtain A Letter of Medical Necessity (LMN or Rx)

    What is this?
    
    A prescription is an order written by a doctor stating that a patient is in need of equipment.
    
    A Letter of Medical Necessity or LMN is a prescription, order or letter that states "lifetime duration" or "lifetime need". Typically, an LMN provides greater detail about the need for equipment and additional dispenable supplies. This is our preferred document since it means you will have to submit less documentation in the future.
    
    Components
    
    We must have an order from the doctor before dispensing equipment to our patient. The dispensing order must include:
    
    

    • Description of the item(s) prescribed
    • Duration of each item (Lifetime duration is ideal, but not required)
    • Beneficiary's name
    • Name, UPIN and License Number of the Physician
    • Date of the order
    • Diagnosis Code

    
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    #4 Select Your Equipment

    A wide variety of high end CPAP, APAP and BiPAP Equipment is available to Medicare beneficiaries through our service. If you have questions or need help selecting, we are available to help.
    
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    Reminders and Repeat Orders

    Reminders and Repeat Orders We will never ship you products you have not requested. We set equipment reminders set at your schedule with your approval. We can follow up with you via phone, email or standard mail.
    
    Once your file with us is complete you will be able to receive replacement supplies as set by your insurance plan using the information already assembled for claim submission. A new file will not have to be compiled.
    
    

    With your permission, we will keep your information on file so that when it's time T for new supplies, you won't have to compile paperwork; just indicate your preferences when we remind you, let us know what you need and your equipment will be shipped to your doorstep!

    You can choose how you would like to be reminded:

    • Follow Up With Me By Phone.
      • Our most popular option. We will follow up with our patients regularly via phone to check on their treatment status.

      Follow Up With Me By Email.

      • We will follow up with our patients regularly via email to check on their treatment status.

      Do NOT Monitor My Status.

      • For patients who are making one-time transactions.
      • We will not follow up with these patients to track their treatment status.*

      *Please note that Medicare providers are required to confirm that CPAP beneficiaries are using their prescribed equipment. This follow up will be placed regardless of your contact preference in accordance with Medicare guidelines. This confirmation generally takes place from 61 to 90 days after the initial CPAP setup.
      
      In order to continue your service past this 61-90 day time period we need to ask you the following questions:

      • Are you (the Medicare beneficiary) now using a machine that helps you take your breaths while you are asleep (separate from a machine that may be giving you oxygen or medicine)?
      • How many hours per day do you usually use this machine?
      • How many months have you been using this machine?
      • Will you keep using this treatment in the future?
      • Secondary Insurance
      • Letter of Medical Necessity (LMN)
        • Only if the LMN you submitted to us during your first order did not have a lifetime duration stated.

        
        
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        Will I be able to receive a replacement CPAP, APAP or BiPAP?

        Medicare views CPAP, APAP and BiPAP devices capped rental items. Medicare guidelines state that a reasonable useful lifetime for capped rental equipment cannot be less than five years. In general, if a CPAP, APAP or BiPAP been in continuous use by the patient, on either a rental or a purchase basis, for the equipment's useful lifetime or if the item is lost or irreparably damaged, the patient may elect to obtain a new piece of equipment.
        
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        What will I learn from an insurance verification?

        Once we have completed a verification of your insurance coverage we will tell you the following, free of charge:

        • If your plan covers the diagnosis of sleep apnea.
        • If your plan covers durable medical equipment. CPAP/APAP/BiPAP machines and supplies fall under this category of coverage.
        • If BillMyInsurance shows as an In Network Provider for your plan.
        • What percentage of the cost of equipment will be covered by your plan.
        • What your yearly deductible is for durable medical equipment.
        • An estimate of your co-pay for the equipment your are interested in receiving.

        
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        Will I have a payment at the time of shipping?

        If you are a Medicare holder, you will not have any payment due at the time of shipping. If you have a secondary insurance, we will submit a claim to that insurance after Medicare makes payment. If you do not have a secondary insurance, you will receive an invoice for the 20% not covered by Medicare after Medicare has made payment. Neither you nor Medicare will pay any shipping costs.
        
        If you are a commercial or private insurance holder, such as Blue Cross Blue Shield, whether or not you have a co-payment due at the time of shipping is determined by your insurance plan. We will provide you with an estimated co-pay following verification of your insurance coverage. If your plan covers the treatment of sleep apnea at 100% with no yearly deductible, then you will have no co-payment to meet. Your only cost will be for shipping. If, however, your plan covers a percentage of the treatment of sleep apnea cost, or if your plan has a deductible that is unmet, you will have a co-payment and shipping fee.
        
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        What does "In Network" mean?

        In order for a provider of service such as a doctor, hospital, diagnostic laboratory, or DME ("durable medical equipment") company to submit claims to an insurance company as an "In Network Provider". That is, the provider of the service must have a contract in place with the insurance company.
        
        That contract is an agreement regarding the price of services between the service provider and the insurance company. When a provider is "In Network", the cost of the services provided by that provider are considered for reimbursement at "In Network" rates.
        
        For example: If your plan covers in network services at 80%, you will be responsible for the remaining 20% of the contracted rate.
        
        If you have a secondary insurance that routinely covers the cost of the service you received, the 20% not covered by your primary insurance can be billed to the secondary insurance for consideration of payment.
        
        If your plan has a yearly deductible in place, that deductible has to be satisfied before the insurance company reimburses for the cost of the service.
        
        For example: Let's say your plan has a $250.00 yearly deductible which has not yet been met, and the plan covers at 90%. The first $250.00 of the cost of your equipment goes towards meeting the deductible. Of the amount remaining after the deductible is met, your insurance will cover 90% of the contracted rate and you will be responsible for the remaining 10%.
        
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        What does private insurance cover?

        Insurance plans vary greatly from one to another. The only way for us to know what your plan will allow is through an insurance verification.
        
        The conditions of coverage for sleep therapy range from 100% coverage with no yearly deductible, to 50% coverage for in network services with a $5,680.00 yearly deductible. Additionally, not all plans cover the treatment of sleep apnea.
        
        The amount you pay for an an office visit with your physician does not determine your coverage for durable medical equipment. CPAP, APAP and BiPAP machines and the supplies needed to use them fall under the catagory of durable medical equipment. Many plans do cover replacement supplies (mask, headgear, hose and filters.) Other plans do not cover supplies at all.
        
        You will be provided with a co-pay estimate following verification of your coverage and an explanation of what your plan covers.
        
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        What does "Out of Network" mean?

        A provider of service which does not have a contract in place with a particular insurance company is considered "Out of Network". In this case, the reimbursement for the services received from that provider are considered at Out of Network rates. In most cases, out of network services are covered at a lower rate of reimbursement, and the cost of the service is higher.
        
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        Can I find out what my insurance plan covers on my own?

        You can easily check if your insurance covers the treatment of sleep apnea.
        
        Contact your insurance company using the Customer Service or Beneficiary Services phone number on your insurance card. Generally speaking, the contact information is on the back of the card.
        
        You will be checking on Durable Medical Equipment (DME) coverage for the treatment of sleep apnea or sleep disorders. The most commonly applied diagnosis code for sleep apnea is 780.53. Have you policy ID and Group ID handy and be prepared to take notes.
        Ask:
        Does my plan cover the treatment of sleep apnea (use the diagnosis code if needed)?
        What percentage of coverage do I have if using an In Network Provider?
        What is my yearly In Network deductible and how much of it is met at this time?
        What percentage of coverage do I have is using an Out of Network Provider?
        What is my yearly Out of Network deductible and how much of it is met at this time?
        Insurance Billing Codes for equipment associated with the treatment of sleep apnea:
        CPAP or APAP machine = E0601
        Heated Humidifier = E0562
        Nasal mask = A7034
        Headgear = A7035
        Full Face mask = A7030
        Tubing or Hose = A7037
        Fine (Disposable) Filter = A7038
        Washable (Foam) Filter = A7039
        Occasionally, information is delivered very quickly. If you are unclear about anything you hear, ask for a clarification. If you are considering self-filing a claim, ask the representative what information needs to be submitted along with a claim. The most commonly requested pieces of documentation are the complete sleep study, a prescription and a letter of medical necessity.
        
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        Will my insurance cover the cost of software and DC power equipment?

        Unfortunately, neither Medicare nor private commercial insurances cover software, smart card readers, DC batteries or cables. You will, however, be able to make a self purchase of these items at www.cpap.com.
        
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        If I call you with my plan name, can you tell me what my co-pay will be?

        The benefits available to your through your insurance coverage are specific to your plan as associated with your policy or Member ID and Group ID. The only way to know what your plan covers is for a verification of benefits to be completed by contacting your insurance company.
        Plan benefits vary greatly from one to another. Not all Blue Cross Blue Shield plans have the same benefits. Even within the same company, one employee may have chosen one benefit plan available and a co-worker may have chosen an entirely different level of coverage.
        There is no obligation to you to go forward with receiving equipment through BillMyInsurance.com should you choose not to do so.
        
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        Am I obligated to go to receive equipment if I complete the form?

        There is no obligation to receive equipment through BillMyInsurance after completing the form. Nothing will be shipped to you and no claims will be submitted to your insurance. If you are not satisfied with the co-pay estimate given to you following insurance verification, simply let us know you would like to close your inquiry with us.
        
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        Blue Cross Blue Shield

        We will show as In Network for many Blue Cross Blue Shield PPO and Federal plans.
        Although only verification of your coverage will allow us to determine your estimated copay amount, these plans generally cover any equipment you choose.
        Blue Cross Blue Shield regional or state plan names include, but are not limited to:
        Anthem
        CareFirst
        Empire
        HealthKeepers
        Horizon
        
        
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        Our Company

        BillMyInsurance.com is a durable medical equipment company specializing in the treatment of sleep apnea. We carry CPAP, APAP and BiPAP machines and the supplies needed to use them.
        
        We submit claims to Medicare and to private insurance companies. We are an authorized Medicare CPAP Provider and we accept Medicare assignment. We are in network for many private insurance PPO insurance plans. We build a complete file to meet the insurance company guidelines, submit a claim to the insurance company or companies, and we are reimbursed based on the contracted rates for the CPAP equipment.
        
        In order for us to verify your coverage fill out our on line form. You are under no obligation to enroll with us and there is no time limit on your call. You are free to spend as much time learning about the process and asking questions as you need.
        
        Our brick and mortar operations have been processing Medicare and private insurance claims for 15 years. Our process is efficient and informative. Even if we can not work with your insurance provider, our free insurance verification can tell you exactly where your insurance carrier stands in regards to providing you with a CPAP.
        
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