Upper Billing Limits Update

The policies below are linked in the Alliance’s April 1, 2019 Provider Manual, currently published on the Alliance provider website at www.ccah-alliance.org/provider-manual-toc.html. As described within these policies, effective April 1, 2019, providers will be required to submit invoices for some durable medical equipment (DME) products to demonstrate that claims are submitted appropriately and in alignment with upper billing limit guidelines.

• Policy: 600-1801: Claim Submission Guidelines and Rental Timeframes for Nebulizers
• Policy: 600-1802: Claims Submission Guidelines and Rental Timeframes for Transcutaneous
  Electrical Nerve Stimulation (TENS) Device
  • Unless a supporting invoice accompanies a claim, the maximum reimbursement rate for a nebulizer will be $90 and the maximum reimbursement rate for a TENS device will be
    $155. When accompanied by an invoice, the Alliance will pay the lesser of two times the invoice amount or the Medi-Cal posted rate.
  • Unless a supporting invoice accompanies a claim, the maximum rental period is six months. Total rental payments may not exceed the base payment rate of $90 for a
    nebulizer and $155 for a TENS device. When accompanied by an invoice, the Alliance will make rental payments up to the lesser of two times the invoice amount or the Medi-Cal posted rate.
• Policy: 600-1803: Claims Submission Guidelines and Rental Timeframes for Wheelchairs
• Policy: 600-1804: Claims Submission guidelines for Osteogenesis Stimulators
• Policy: 600-1805: Claims Submission Guidelines for Speech Generating Devices
  • Supporting invoices will be required for all speech generating devices, osteogenesis stimulators and wheelchair purchases. The Alliance will pay the lesser of two times the invoice amount or the Medi-Cal posted rate.

For more information, please contact a Provider Relations Representative at (800) 700-3874, ext. 5504.