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Patient Bill of Rights
Insurance & Financial Policy
Financial Responsibities

PAP Setup Information for New Patients

At Sleep Source, we understand that success with therapy begins with proper education. Your PAP specialist will review the following information with you at your PAP setup, which we have made conveniently available on our website should you need to refer to this information in the future or if you are a prospective patient wanting to learn more about getting a CPAP/BIPAP from Sleep Source. Please use the guide to the left to navigate to a specific page.

Patient Bill of Rights

As a patient with Sleep Source, you have the right to:

  • Be given information about your rights and responsibilities relative to health care services.

  • Receive a timely response from Sleep Source regarding your request of home care services.

  • Be given information about Sleep Source’s ownership, policies, procedures and charges for services, including your eligibility for third party reimbursement

  • Choose your home care service company provider.

  • Be given appropriate and quality home care services without discrimination due to race, creed, color, religion, sex, national origin, sexual preference, handicap or age

  • Be treated with courtesy and respect by all who provide services to you.

  • Be free from physical and mental abuse, neglect and exploitative practices.

  • Be given proper identification by name/title of everyone who provides service to you.

  • Be given necessary information so that you will be able to give informed consent for services prior to start of any service.

  • Register any complaints regarding services with Sleep Source and/or appropriate state agencies.

  • Be given an assessment and update of your developed home care service plan at your request.

  • Be given data privacy and confidentiality.

  • Respect for your property and belongings.

  • Review your client file at your request.

  • Be given information regarding anticipated transfer of your services to another provider and/or termination of services.

  • Voice grievances without being threatened, restrained or discriminated against.

  • Be fully informed in advance about care/service to be provided, including the disciplines that furnish care and the frequency of visits, as well as any modifications to the plan of care.

  • Refuse care or treatment after the consequences of refusing care or treatment are fully presented.

  • Have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated.

  • Be informed of any financial benefits when referred to Sleep Source.


As a home care service recipient, you have the responsibility to:

  • Provide accurate and complete health information concerning your past illnesses, hospitalizations, medications, allergies and other pertinent information.

  • Report perceived risks in your care and unexpected changes in your condition.

  • Assist in developing and maintaining a safe environment and provide feedback about service needs and expectations.

  • Ask questions when you do not understand care, treatment, and services or expectations.

  • Provide information regarding concerns and problems you have to a Sleep Source representative.

  • Adhere to your developed plan of service and for the outcomes when the plan of service is not followed.

  • Inform Sleep Source when you will not be available for a scheduled home or office visit.

  • Provide accurate and timely documentation for third party payer reimbursement and personal financial responsibilities.

  • Be considerate of Sleep Source's staff and property and to follow Sleep Source's rules and regulations.

Insurance and Financial Policy

Sleep Source is committed to providing you with the best possible service. If you have medical insurance, we are eager to help you receive the maximum benefits available to you. In order to achieve this goal, we need your assistance and understanding of our insurance and financial policy. We will gladly attempt to answer your insurance-related questions, but you should be aware of the following information.

Your insurance is a contract among you, your employer (if applicable), and your insurance company. We are not a party to that contract.

 

Not all services are considered “covered services” by every insurance carrier and some insurance companies arbitrarily select services they will not cover. We suggest you read your individual contact carefully and direct any questions you have about that coverage to their attention.

Generally, most insurance companies pay a percentage (such as 80%) of a given service after "deductible", the amount that you are required to pay toward your healthcare before your insurance contributes payment. The percentage that you owe after your deductible is satisfied is called the "coinsurance". Sleep Source files "charges" for a service to your insurance company that are "adjusted" to an "allowable amount", an amount set forth by your insurance company that they allow a provider to collect for a service. The "adjustment" from Sleep Source's "charges" is an amount that Sleep Source can neither collect from you nor be reimbursed for by your insurance company.

Your "explanation of benefits" is the document that breaks down the charges, adjustments, allowable amounts, and which portion of those amounts are subject to your deductible and/or coinsurance. This document lists your overall patient responsibility for services provided as well as the portion paid for by your insurance. As part of Sleep Source's participating provider agreement your insurance, we are obligated to charge you or not charge you based on your explanation of benefits.

 

If your insurance carrier requires a referral from your doctor or an authorization from them as a condition of payment for the services rendered, it is important you understand that you are responsible for obtaining such a referral or authorization prior to commencement of the services we will provide you. If you need assistance, please contact our office and the email address or number below.

In accordance with Federal Statutes and State Balance Billing Law, Sleep Source must balance bill for all outstanding charges. Therefore, after your insurance claim is filed and either payment has been received or the claim is denied, you will be billed for any remaining balance. In the event that we receive no response from your insurance carrier, you will be billed for the full amount. Payment for services rendered is due at the time you receive your bill.

In order to be covered for ongoing charges for manufacturer-recommended replacement of accessories (like filters, cushions and tubing), most insurance companies require follow-up confirmation of your continued use (compliance) of the PAP machine. If you are non-compliant in meeting your insurance company’s usage requirements you will be responsible for any resulting charges.

It is important to remember that our relationship is with you and not your insurance company. We file claims as a courtesy to you, but all charges are your responsibility. We recognize that patients may encounter financial challenges from time to time that may affect timely payment of our charges. If you are experiencing financial difficulties we encourage you to contact our office promptly for assistance, as balances left unpaid may be sent to a third party collections agency.

If you have any questions about any of the above or any uncertainty about your insurance coverage, please feel free to send us an email at support@sleepsourcedme.com or contact us at (586) 298-6927. We will be more than happy to assist you.

Explanation of Financial Responsibilities

Before receiving your new PAP machine, an introductory call from the staff at Sleep Source should have been made during which your financial responsibilities were estimated and explained per your expected insurance coverage (or lack thereof). The experienced staff at Sleep Source prepares for this introductory call by researching your benefits relative to the services you will be receiving. This guide will further elaborate on what to expect financially when either using insurance to purchase/rent your PAP machine and supplies or directly purchasing from Sleep Source.


Insurance Benefits Explained

Primarily, the deductible and coinsurance for durable medical equipment are what dictate your coverage for your PAP machine and supplies. In any given "deductible year" (from the date your insurance coverage starts every year), your insurance company applies your medical costs to your deductible until that amount has been met. Once the amount of the deductible is met, the insurance company will cover a percentage of your PAP machine and supplies according to the coinsurance, which is the percentage you are required to pay for them. The insurance allowable is the price set by your insurance company that they will pay for your services.

Note that some insurances waive coinsurance/deductible requirements for PAP machines and supplies. Some insurances also have out-of-pocket or coinsurance limits that, if met, waive coinsurance requirements. Insurances with family deductibles may meet either their family or individual deductible in order to receive coverage based on their coinsurance. Sleep Source takes all of this into account when estimating your financial responsibilities.


Renting vs. Purchasing PAP Machines

The majority of insurance companies are requiring that PAP machines be rented as opposed to outright purchasing them. This is because the insurance companies require to see evidence of the patient actively using their PAP machine. Most commonly, PAP machines are billed for over a 13 month (sometimes 10 month for insurances like Medicaid) "capped rental" period in which after renting the machine for that duration, the patient will own the machine and no further rental charges will be incurred. This will consist of 13 payments that are billed one month apart. Some insurances also allow for an outright purchase. If these options are applicable, Sleep Source will do its inform you of the most financially advantageous option, but you may contact our staff about changing your method of purchase if possible.

Allowable prices for each type of device will vary from insurance to insurance, but below are the current ones based on Blue Cross Blue Shield of Michigan insurance:

  • APAP and CPAP with heated humidifier: $68.18 per month (13 months), or $886.34 full purchase

  • BIPAP S mode with heated humidifier: $142.36 per month (13 months), or $1850.68 full purchase

  • BIPAP ASV or ST modes with heated humidifier: $356.19 per month (13 months), or $4630.47 full purchase

Note that, when renting a PAP machine, your deductible may reset before your payments are finished. Sometimes this means despite meeting your deductible in the previous year, you will have payments applied to next year's deductible.


Receiving Supplies for PAP Machines

Supplies for PAP machines have their own costs associated with the type of part they are as well. Allowable prices will vary with each insurance plan. Your first bill will include charges for your tubing and mask. Sleep Source will never send replacement supplies without prior consent, however your supplies will wear out and need to be replaced periodically. See Instructions on Cleaning and Replacing Supplies for more information. Below is a chart of expenses related to PAP supplies based on Blue Cross Blue Shield's current allowable amounts:

HCPCS Code
Description
Part Type
Allowable Amount
A7037
Pos airway pressure tubing
Non-heated tubing
$22.05
A7046
Repl water chamber, pap dev
Water chamber
$17.45
A7039
Filter, non dispoable w pap
Reusable filter
$9.61
A7038
Pos airway pressure filter
Disposable filter
$3.11
A7036
Pos airway pressure chinstrap
Chinstrap
$13.80
A7035
Pos airway pressure headgear
Headgear (mask strap)
$27.27
A7034
Nasal application device
Nasal mask (frame only)
$82.14
A7033
Replacement nasal pillows
Nasal pillows
$21.54
A7032
Replacement nasal cushion
Nasal cushion
$27.55
A7031
Replacement facemask interface
Full face cushion
$48.93
A7030
Cpap full face mask
Full face mask (frame only)
$130.55
A4604
Tubing with heating element
Heated tubing
$53.50

Purchasing PAP Machines and Supplies Directly from Sleep Source

If you are uninsured or wish to purchase any PAP machines or supplies directly through Sleep Source, you will be given an invoice with our pricing before you commit to a purchase. Sleep Source does offer payment plans for patients who wish to purchase any PAP machine directly through us and we will work with you to meet your financial needs.


Additional Assistance

If you need any additional assistance in estimating your costs in paying for your PAP machine and supplies or clarification on what your benefits mean financially, our staff members at Sleep Source will be happy to help you and can be reached by phone at (586) 298-6927, extension 3 or by email at support@sleepsourcedme.com.

Credit Card on File Policy & Agreement

Sleep Source’s Credit Card on File Policy requires all new patients (“Patient(s)”) who elect to use their insurance as a means of paying for medical services with Sleep Source, LLC (“Sleep Source”) to have a credit or debit card on file prior to services being rendered. Credit and debit cards are stored securely in a PCI compliant payment gateway.

 

By signing the Credit Card on File Agreement (“Agreement”), the Patient understands the following:

 

  • Sleep Source will file insurance claims on behalf of the Patient per its Insurance & Financial Policy.

  • Once the Patient’s claim is processed and the corresponding Explanation of Benefits (“EOB”) is received by Sleep Source, a statement will be mailed to the address on file for any amount that is designated as the Patient’s responsibility on the EOB.

    • Charges that the Patient may be responsible for can be classified as deductible, coinsurance, copay, or denied charges. Deductibles, coinsurance, and copays are charges based on the Patient’s Summary of Benefits for covered charges. Denied charges are based on services ineligible for coverage that may be based on a variety of factors such as lack of precertification, benefit maximum reached, terminated insurance policies, policy guidelines not met, etc.

      • Sleep Source will make every possible effort to resolve denied charges. If Sleep Source is unable to resolve denied charges, they will remain the responsibility of the Patient to pay. Sleep Source will apply a self-pay courtesy discount if applicable.

  • Payment is due within 30 days of the date the statement is issued to the Patient. The date that is 30 days after the statement is issued is considered the “Due Date”.

  • By signing this Agreement, the Patient authorizes Sleep Source to charge their credit or debit card on file for any outstanding balance not paid by the Due Date.

    • A payment plan can be arranged with Sleep Source if requested before the Due Date. Please contact Sleep Source’s billing department directly to make such an arrangement.

    • The Patient will receive a notice via text, email, or voicemail at least 24 hours prior to the payment method on file being charged.

    • The Patient may request an account review prior to charges being filed. If no discrepancies are found or if a self-pay courtesy discount is applied to the balance, the credit or debit card on file will still be charged following the conveyance of results for an account review. If the statement must be fixed to accurately reflect the corresponding EOB(s) for a service or services, a new statement will be issued to the Patient and an additional 30 days provided to remit payment.

  • All services that are in-eligible for payment by the Patient’s insurance, or if the Patient does not have current eligible insurance coverage, are due before or upon receipt of services rendered by Sleep Source.

Compliance Requirements for Continuing Coverage

The first 90 days of your treatment is considered by your insurance carrier as a trial period for your PAP usage. It is imperative that you meet the below requirements within these initial 90 days* to ensure continued coverage and payment of your PAP equipment:

  1. Use your PAP at least 4 hours per night, for at least 21 nights**, over a consecutive 30 day period (70% of nights).

  2. Schedule a follow up re-evaluation appointment with your treating doctor (the doctor who prescribed your PAP machine). The evaluation must take place between 31 and 90 days after your initial set-up date once you have achieved compliant usage as described in the first step. You may have to bring your equipment to this appointment.
     

PLEASE BE AWARE, THAT IF YOU DO NOT COMPLY WITH BOTH REQUIREMENTS ABOVE, YOUR INSURANCE CARRIER WILL NOT CONTINUE TO PAY YOUR MONTHLY RENTAL EXPENSES OR SUPPLIES BEYOND 90 DAYS AND YOU WILL EITHER HAVE TO PAY ANY REMAINING BALANCES OR RETURN THE EQUIPMENT TO SLEEP SOURCE.

* There are cases where patients do not meet the compliance requirements within the first 90 days of treatment that may want to continue their treatment. If this happens to you or you are not adhering well to the treatment, please contact the staff at Sleep Source for assistance and be sure to make a follow-up visit with your treating doctor to request a 90-day extension for your trial period. Most insurances require in-lab testing as a condition of the extension

** While sleeping for 70% of nights for at least 4 hours satisfies insurance requirements, Sleep Source does recommend daily use of your PAP machine to maximize your treatment benefits.

Plan of Service

PLAN OF TREATMENT GOALS 


SHORT-TERM GOALS - FIRST 30 DAYS: 

1) Desensitize to mask and pressure 

2) Use PAP consistently for greater than 4 hours per day 

  

LONG-TERM GOALS - FIRST 6 MONTHS: 

1) Improve daytime sleepiness and alertness 

2) Reduce apnea episodes to normal range and eliminate snoring 

3) Improve quality of sleep 

  

ONGOING GOALS 

1) Continued use of PAP every night for over 4 hours a night 

2) Keep apnea episodes within normal range 

  

FOLLOW UP: 

  • Verbal follow-up 1 week after setup

  • Clinical follow-up 61-90 Days after setup and annually

  • Verbal/in-person follow-ups as necessary to troubleshoot issues

Maintenance and Replacement of PAP Equipment

Your PAP machine is an important investment in your sleep health - proper care and maintenance of your PAP equipment is essential in order to receive the maximum benefits from it as well as prolonging its longevity. 

Equipment Maintenance:

  • Avoid using a dishwasher, bleach, chlorine, alcohol, or moisturizing/aromatic-based solutions to clean your PAP equipment.

  • Machine: The outside of the PAP machine itself does not require regular maintenance, but may be cleaned with a lightly damp cloth and mild soap or non-alcoholic wipes as necessary. NEVER leave the machine plugged in while doing this, and make sure it is dry before plugging the power cord back in.

  • Water Chambers: When refilling the water chamber, always use distilled water. Dump out any leftover water in the morning and allow it to air dry. The water chamber can be washed with a mild soap and water by hand scrubbing or soaking in the sink or bathtub for at least 10 minutes. Air dry when finished. Soaking the water chamber in a 1/3 white distilled vinegar to 2/3 distilled water solution for an hour can sterilize it and remove any film build-up.

  • Tubing: The tubing can be washed with a mild soap and water. Soaking in the sink or bathtub is recommended for for at least 10 minutes, but using a gentle brush to clean inside the tubing will work as long as caution is exercised. Air dry when finished.

  • Masks: The face mask can be gently hand-washed using a mild soap (baby shampoo is most recommended) and water. The frame and headgear parts of the mask should be cleaned at least once a week and the cushion or pillows should be cleaned daily, as natural oils from the face will wear down its longevity as well as make-up and moisturizers. Air dry when finished.

    • Note: The AirTouch cushion is unique due to its memory foam design and should only be cleaned with non-alcoholic wipes.

  • Filters: All machines should use disposable filters which can simply be discarded when dirty. Inspecting these for discoloration every couple of weeks is recommended. If your machine has a reusable filter as well, hand scrub it with a mild soap and water every week to clean it and allow it to air dry before putting back in the machine.

  • Cleaning Intervals: It is recommended to clean your equipment at least once a week. Daily cleaning of the mask cushion/pillows is optimal.

Patient Portal and e-Contact

To help our patients manage their sleep therapy needs, Sleep Source has developed a patient portal and notification system for reordering supplies, appointment and prescription refill reminders, and more! Here are some of the benefits of using the patient portal and e-Contact reminders:

 

  • Using the patient portal, you can easily view your insurance eligibility for ordering supplies and place an order at any time, as well as see your order history, equipment information, and demographic information.

  • With e-Contact, you can receive reminders every 3 months (or annually if Medicaid-insured) to reorder your supplies via text messaging and email. These reminders will contain a link to our patient portal so you can easily sign in and reorder your supplies, as well as additional contact information to place your order. For more details on how often your supplies are covered, see the Equipment Replacement section.​

  • You can also receive e-Contact reminders via email that notify you about your PAP progress, remind you of scheduling appointments for follow-up and renewing your prescription, and invite you to leave feedback.

 

If you elect to join e-Contact, you should receive a welcome email within approximately 1-3 business days containing instructions for setting up your patient portal account. Whitelisting orders@sleepsourcedme.com and portal@sleepsourcedme.com or adding these email addresses to your contacts list will ensure these emails do not go to the junk folder. If an order is successfully placed, a confirmation email will be sent to you with the details of your order. You may email orders@sleepsourcedme.com any time with inquiries about ordering your CPAP supplies or if you are having any issues using the patient portal.

Equipment Replacement

To get the maximum benefit from your PAP therapy, accessories should be replaced due to normal wear and tear that can reduce the efficacy of your treatment. Over time, some accessories can also build up bacteria in spite of regular cleaning. Most insurance companies appreciate these conditions and adhere to Medicare's schedule for replacing CPAP supplies (one notable exception includes Medicaid).
 

Insurance Recommendations for CPAP Supply Replacement

Part Type
HCPCS Code
Replacement Schedule (Standard)
Replacement Schedule (Medicaid)
Non-heated tubing
A7037
1 per 3 months
1 per year
Water chamber
A7046
1 per 6 months
2 per year
Reusable filter
A7039
1 per 6 months
N/A
Disposable filter
A7038
2 per 1 month
18 per year
Chinstrap
A7036
1 per 6 months
1 per year
Headgear (mask strap)
A7035
1 per 6 months
1 per year
Nasal mask (frame only)
A7034
1 per 3 months
1 per year
Nasal pillows
A7033
2 per 1 month
2 per year
Nasal cushion
A7032
2 per 1 month
2 per year
Full face cushion
A7031
1 per 1 month
2 per year
Full face mask (frame only)
A7030
1 per 3 months
1 per year
Heated tubing
A4604
1 per 3 months
N/A

Equipment Warranty and Returns Policy

PAP Device Returns and Warranty Information

All devices sold new or via capped rental by Sleep Source carry a two (2) year manufacturer’s warranty. During this warranty period, Sleep Source will coordinate the repair or replacement of any defective devices at no charge to the patient contingent to the guidelines of their respective warranties. Prior to a device’s repair or replacement, the device must be returned to Sleep Source for examination. Any devices that have been tampered with or used in such a way that voids the warranty will not be eligible for free replacement or repair. All devices include an owner’s manual containing the details of the device’s warranty. Please contact Sleep Source for troubleshooting of the device before returning it.

All previously owned refurbished devices carry a six (6) month minimum warranty from Sleep Source. Each device may or may not carry additional warranty coverage from the manufacturer. Sleep Source’s warranty policy follows the same guidelines as the manufacturer’s warranty and the same procedure as other devices.

Repairs of devices after the warranty period will be subject to costs dependent on the manufacturer and nature of the device’s problem. Each policy varies by manufacturer and some may charge a diagnostic fee. Shipping charges are the responsibility of the patient.

Returns of devices are subject to the method of purchase. If a device is subject to a capped rental, the patient is responsible for all incurred rental charges up to the date of return. Rental fees are charged starting on the day of the device setup and continue every month after for the duration they apply. Devices that are returned with any damage or wear-and-tear will be subject to additional charges at Sleep Source's discretion. Sleep Source does not accept the return of purchased devices. Unwanted devices may be sold back to Sleep Source at its sole discretion.

PAP Accessories and Supplies Returns Information

Accessories and supplies sealed in their original packaging may be returned for a full refund within 14 days of receipt. Accessories and supplies sealed in their original packaging or ones that arrived in a defective condition may be exchanged within 30 days of receipt. The costs of any applicable shipping for returns will be the responsibility of the patient except in the cases of incorrect order fulfillment or receipt of defective equipment.

 

30-Day Mask Guarantee
Under Sleep Source’s 30-Day Mask Guarantee program, patients who are dissatisfied with their current mask can exchange it and be re-fitted with a different one within 30 days of its receipt at no additional charge to the patient. This program is only offered once to first time customers - subsequent mask changes are subject to charges. Please contact the main office or your setup specialist with details of your mask and device usage for assistance in troubleshooting your mask issues.

Home Safety Assessment

Please ensure the following guidelines are met for safe use of your equipment:

  • Place your PAP device on a clean, dry, and level surface.

  • Avoid using an extension cable to power your PAP device.

  • Ensure that smoke detectors are functional and installed on every level of your home.

  • Have an established fire escape route in place at home.

  • Have functional fire extinguishers in your home.

  • Ensure that electrical plugs in your home are grounded and checked periodically by voltage meter.

Service Details and Backup Plan

Sleep Source has the required training and personnel to provide home healthcare services that encompass home-based products and services.

To provide the specific care, treatments, and services, Sleep Source has professional staff that has received on-the-job training, advanced formal education, and/or licenses or certificates.

When Sleep Source bills an insurance provider, the bill is on behalf of you, the patient. Sleep Source accepts most forms of payment, including cash, check and credit/debit/HSA cards.

Sleep Source's hours of operation are Monday through Friday from 9:30am to 4:00pm. Sleep Source is closed on weekends and the following holidays: New Year's, Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas Eve, Christmas.

Sleep Source provides the specific care, treatment, and services in a geographic area that includes the entire state of Michigan.

If a patient feels they are experiencing a life-threatening event and they place a call to Sleep Source, they will be instructed to immediately hang up and dial 9-1-1, the emergency medical system (EMS). Sleep Source does not accept advance directives.

Sleep Source prides itself that all employees are trained to listen to patients and clients to continually strive to provide the best possible service. If you would like to provide any feedback, whether positive, negative, or neutral, please feel free to provide us with your comments. You can provide them, anonymously if desired, by any one of the convenient means below:

Our toll-free number is (877) 333-6335, and our website can be visited at https://www.sleepsourcedme.com at any time.

 

Equipment Failure Backup Plan

In the event that your PAP device fails or has a malfunction, Sleep Source can provide a loaner device to use while your device is sent in for repair. Please call Sleep Source immediately to troubleshoot any issues with your device and/or to promptly arrange for a replacement or loaner device. 

Customer Complaint Procedure

The management of patient and client complaints or grievances is handled by an internal tracking and management system that is designed to address each case in an expedient and thorough manner. Presently, management, with the help of the system, is involved in every aspect of the process to ensure all issues are addressed in a professional manner.

If Sleep Source provided your care, treatment, or service and we were unable to answer all your questions or address your concerns, complaints, or grievances in a manner you thought was appropriate, you have the right to contact the following organizations about our conduct:

        Medicare
        Phone: 1-800-MEDICARE (1-800-633-4227)
        Website: https://www.medicare.gov/

 

        Accreditation Commission for Health Care (ACHC)
        139 Weston Oaks Ct
        Cary, NC 27513
        Phone: 919-785-1214
        Website: https://www.achc.org/

        HHS Office of Inspector General (OIG)
        ATTN: OIG HOTLINE OPERATIONS
        PO Box 23489
        Washington, DC 20026
        Phone: 1-800-HHS-TIPS (1-800-447-8477)
        Website: https://oig.hhs.gov/fraud/report-fraud/

        Medicaid Fraud and Abuse – Office of Inspector General
        PO Box 20062
        Lansing, MI 48909
        Phone: 1-855-643-7283
        Website: https://www.michigan.gov/mdhhs/assistance-

        programs/healthcare/hifa/report-medicaid-fraud-and-abuse

 

        State of Michigan – Department of Licensing and Regulatory Affairs (LARA)
        Bureau of Health Care Services
        611 W Ottawa St, PO Box 20664
        Lansing, MI 48909
        Phone: 1-517-335-1980
        Website: https://www.michigan.gov/lara/bureau-list/bchs/complaint

Medicare DMEPOS Supplier Standards

Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c).

  1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.

  2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.

  3. A supplier must have an authorized individual (whose signature is binding) sign the enrollment application for billing privileges.

  4. A supplier must fill orders from its own inventory, or contract with other companies for the purchase of items necessary to fill orders. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or any other Federal procurement or non-procurement programs.

  5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.

  6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.

  7. A supplier must maintain a physical facility on an appropriate site and must maintain a visible sign with posted hours of operation. The location must be accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.

  8. A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards.

  9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited.

  10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.

  11. A supplier is prohibited from direct solicitation to Medicare beneficiaries. For complete details on this prohibition see 42 CFR § 424.57 (c) (11).

  12. A supplier is responsible for delivery of and must instruct beneficiaries on the use of Medicare covered items, and maintain proof of delivery and beneficiary instruction.

  13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.

  14. A supplier must maintain and replace at no charge or repair cost either directly, or through a service contract with another company, any Medicare-covered items it has rented to beneficiaries.

  15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.

  16. A supplier must disclose these standards to each beneficiary it supplies a Medicare-covered item.

  17. A supplier must disclose any person having ownership, financial, or control interest in the supplier.

  18. A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number.

  19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.

  20. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.

  21. A supplier must agree to furnish CMS any information required by the Medicare statute and regulations.

  22. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment for those specific products and services (except for certain exempt pharmaceuticals).

  23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened.

  24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.

  25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.

  26. A supplier must meet the surety bond requirements specified in 42 CFR § 424.57 (d).

  27. A supplier must obtain oxygen from a state-licensed oxygen supplier.

  28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 CFR § 424.516(f).

  29. A supplier is prohibited from sharing a practice location with other Medicare providers and suppliers.

  30. A supplier must remain open to the public for a minimum of 30 hours per week except physicians (as defined in section 1848(j) (3) of the Act) or physical and occupational therapists or a DMEPOS supplier working with custom made orthotics and prosthetics.

DMEPOS suppliers have the option to disclose the following statement to satisfy the requirement outlined in Supplier Standard 16 in lieu of providing a copy of the standards to the beneficiary.

The products and/or services provided to you by ( supplier legal business name or DBA) are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g. honoring warranties and hours of operation). The full text of these standards can be obtained at http://ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the standards.

Notice of Privacy Practices

Abridged Edition

 

Effective April 14, 2003, the Department of Health & Human Services has implemented a protection for patient health care information.  It outlines who we may disclose information to without your authorization and how we can disclose your protected health information with you authorization as well as how you can gain access to your personal health information or to make a complaint to the Department of Health & Human Services if you feel your protected health information was used in an improper way. This notice will give you a brief description of our entire privacy practices.

USES AND DISCLOSURES OR PROTECTED HEALTH INFORMATION

So that this office can treat you, receive payment for that treatment, and run our healthcare operation, we may use your protected health information without your authorization to send to third party payers, administrators, etc.

USES AND DISCLOSURES OR PROTECTED HEALTH INFORMATION THAT MAY BE MADE WITH YOUR WRITTEN AUTHORIZATION

With your signed authorization we may make communications with you to promote products and services that may not be for a specific purpose of providing treatment advice.  You have the right to revoke this authorization.  Other permitted and required authorization uses and disclosures that may be made without your authorization or opportunity to object – we may disclose to a member of your family, a relative, a close friend or other person you identify, your protected health information that directly relates to that persons involvement in you health care.  We may also disclose your protected health information to an authorized public or private entity as required by law.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR CONSENT, AUTHORIZATION, OR OPPORTUNITY TO OBJECT

We may uses or disclose your protected health information in the following situations:

  • Required by law

  • Health Oversight

  • Legal Proceedings

  • Research

Your rights – You may inspect or obtain a copy of your protected health information for as long as we maintain that information unless protected by federal law.

 

RIGHT TO REQUEST A RESTRICTION OF YOUR PROTECTED HEALTH INFORMATION

You may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payment, or health care operation.  Also, you may request that any part of your protected health information not be disclosed to your family members or friends who may be involved in your care.  Your request must be in writing and state specific restrictions requested and to whom it applies.

RIGHT TO REQUEST TO RECEIVE CONFIDENTIAL COMMUNICATION FROM US BY ALTERNATIVE MEANS OR AN ALTERNATIVE LOCATION

You may request that you receive these communications from us at an alternative location or by alternative means than is normally provided to other patients.

RIGHT TO AMEND YOUR PROTECTED HEALTH INFORMATION

You may request that an amendment to your protected health information for as long as we maintain protected health information.  In certain cases we may deny your request for an amendment.

Right to receive an accounting of certain disclosures we have made

You have the right to receive an accounting if we receive a request for disclosure of information for purposes other than treatment, payment, and health care operations.

RIGHT TO RECEIVE A PAPER COPY OF THIS NOTICE

You have the right to receive a complete copy of our privacy practices by – paper or electronically.

COMPLAINTS

If you believe your privacy rights have been violated, you may complain to us or the Secretary of Health and Human Services

This notice was published and becomes effective April 14, 2003.

Continuing Coverage
Plan of Service
Equipment Maintenance
Patient Portal & e-Contact
Equipment Replacement
Warranty & Returns Policy
Home Safety Assessment
Service Details
Complaint Procedure
DMEPOS Supplier Standards
Notice of Privacy Practices
Credit Card on File Policy
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