Or. Admin. Code § 436-009-0080 - [Effective 6/6/2025] Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
(1)
Durable medical equipment (DME), such as Transcutaneous Electrical
Nerve Stimulation (TENS), Microcurrent Electrical Nerve Stimulation (MENS),
home traction devices, heating pads, reusable hot/cold packs, etc., is
equipment that:
(a) Is primarily and
customarily used to serve a medical purpose,
(b) Can withstand repeated use,
(c) Could normally be rented and used by
successive patients,
(d) Is
appropriate for use in the home, and
(e) Is not generally useful to a person in
the absence of an illness or injury.
(2) A prosthetic is an
artificial substitute for a missing body part or any device aiding performance
of a natural function. Examples: hearing aids, eye glasses, crutches,
wheelchairs, scooters, artificial limbs, etc. The insurer must pay for the
repair or replacement of prosthetic appliances damaged as a result of a
compensable injury, even if the worker received no other injury. If the
appliance is not repairable, the insurer must replace the appliance with a new
appliance comparable to the one damaged. If the worker chooses to upgrade the
prescribed prosthetic appliance, the worker may do so but must pay the
difference in price.
(3) An
orthotic is an orthopedic appliance or apparatus used to support,
align, prevent or correct deformities, or to improve the function of a moveable
body part. Examples: brace, splint, shoe insert or modification, etc.
(4)
Supplies are materials that
may be reused multiple times by the same person, but a single supply is not
intended to be used by more than one person, including, but not limited to
incontinent pads, catheters, bandages, elastic stockings, irrigating kits,
sheets, and bags.
(5) When billing
for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS ),
providers must use the following modifiers, when applicable:
(a) NU for purchased, new
equipment;
(b) UE for purchased,
used equipment; and
(c) RR for
rented equipment
(6)
Unless otherwise provided by contract or sections (7) through (11) of this
rule, insurers must pay for DMEPOS according to the following table: [See
attached table.]
(7) Unless a
contract establishes a different rate, the table below lists maximum monthly
rental rates for the codes listed (do not use Appendix E or section (6) to
determine the rental rates for these codes): [See attached table.]
(8) For items rented, unless otherwise
provided by contract:
(a) The maximum daily
rental rate is one thirtieth (1/30) of the monthly rate established in sections
(6) and (7) of this rule.
(b) After
a rental period of 13 months, the item is considered purchased, if the insurer
so chooses.
(c) The insurer may
purchase a rental item anytime within the 13-month rental period, with 75
percent of the rental amount paid applied towards the purchase.
(9) For items purchased, unless
otherwise provided by contract, the insurer must pay for labor and reasonable
expenses at the provider's usual rate for:
(a)
Any labor and reasonable expenses directly related to any repairs or
modifications subsequent to the initial set-up; or
(b) The provider may offer a service
agreement at an additional cost.
(10)
Hearing aids must be
prescribed by the attending physician , authorized nurse practitioner , or
specialist physician . Testing must be done by a licensed audiologist or an
otolaryngologist. The preferred types of hearing aids for most patients are
programmable behind the ear (BTE), in the ear (ITE), and completely in the
canal (CIC) multichannel. Any other types of hearing aids needed for medical
conditions will be considered based on justification from the attending
physician or authorized nurse practitioner . Unless otherwise provided by
contract, insurers must pay the provider's usual fee for hearing
services billed with HCPCS codes V5000 through V5999. However, without
approval from the insurer or director , the payment for hearing aids may not
exceed $7000 for a pair of hearing aids, or $3500 for a single hearing aid. If
the worker chooses to upgrade the prescribed hearing aid, the worker may do so
but must pay the difference in price.
(11) Unless otherwise provided by contract,
insurers must pay the provider's usual fee for vision services
billed with HCPCS codes V0000 through V2999.
(12) The worker may select the service
provider. For claims enrolled in a managed care organization (MCO ) the worker
may be required to select a provider from a list specified by the
MCO .
(13) Except as provided in
section (10) of this rule, the payment amounts established by this rule do not
apply to a worker's direct purchase of DMEPOS . Workers are entitled to
reimbursement for actual out-of-pocket expenses under OAR
436-009-0025.
(14) DMEPOS dispensed by a hospital
(inpatient or outpatient ) must be billed and paid according to OAR
436-009-0020.
Notes
To view attachments referenced in rule text, click here to view rule.
Statutory/Other Authority: ORS 656.726(4)
Statutes/Other Implemented: ORS 656.248
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