R 418.101003b Reimbursement for biologicals, durable medical equipment, and supplies.

Rule 1003b. (1) The carrier shall reimburse durable medical equipment (DME), supplies, and biologicals at Medicare plus 5%. The health care services division shall provide the maximum allowable payments for DME, supplies, and biologicals separate from these rules on the agency website, www.michigan.gov/leo/bureaus-agencies/wdca. Biologicals that have NDC numbers must be billed and reimbursed under R 418.10912. (2) Rented DME must be identified on the provider's bill by RR. Modifier NU identifies the item as purchased, new. (3) If a DME, supply, or biological exceeding $35.00 is not listed in the fee schedule, has no maximum allowable payment (MAP) value in the fee schedule, or is billed with a not otherwise specified code, then reimbursement must be the provider’s acquisition cost, plus a percent mark-up as follows, for purchased DME: (a) Invoice cost of $35.01 to $100.00 must receive cost plus 50%. (b) Invoice cost of $100.01 to $250.00 must receive cost plus 30%. (c) Invoice cost of $250.01 to $700.00 must receive cost plus 25%. (d) Invoice cost of $700.01 or higher must receive cost plus 20%. (4) If rental DME or supplies are not listed in the fee schedule, have no MAP value in the fee schedule, or are billed with a not otherwise specified code, then reimbursement must be 1 of the following: (a) The daily rental rate must be calculated using the provider’s acquisition cost, plus 20% divided by 365. (b) If the provider is the manufacturer of the DME, the daily rental rate must be calculated using the manufacturer’s cost to produce the DME, plus 20% divided by 365. (5) A provider’s failure to provide the required acquisition cost or manufacturer’s cost may result in denial of reimbursement. (6) All items and services associated with the DME rental must be included in the daily rental rate as calculated in subrule (4) of this rule and must not be unbundled and billed separately, unless otherwise indicated in the HCPCS Level II codebook as adopted by reference in R 418.10107.