Submitting an insurance claim for your Broda wheelchair can be a daunting process. Broda products are considered durable medical equipment (DME) or mobility access equipment (MAE). Consult this helpful guide to get you started with the insurance claim process.
Keep in mind that reimbursement and funding of any kind is provided on a case-by-case basis and depends on proof of medical necessity and supporting documentation. Guidelines regarding coverage are updated often, so always validate your information with your insurance provider during the claim process.
How do I submit an insurance claim for a Broda wheelchair?
Before you receive your Broda wheelchair, you will need to submit a claim to your insurance company, Medicare, or Medicaid for funding assistance. There are a few steps that are typically required to submit a claim for durable medical equipment like a Broda wheelchair. Before you get started, it’s important to contact your insurance company to make sure you’re aware of any additional steps specific to your insurance plan.
1. Face-to-Face Evaluation
The first step is to set up an appointment with your primary care provider for a seating assessment, also known as a Face-to-Face Evaluation (FFE). Your medical provider will conduct the FFE to determine your need for the medical equipment.
After the evaluation, your primary care provider will write a detailed prescription for the requested medical equipment. The prescription or written order must be sent to the medical equipment supplier BEFORE the equipment is delivered to you. The prescription date must be on or before the date of delivery.
3. Clinical Documentation
During the funding process, your insurance company will review the contents of your clinical record. It’s vitally important that your documentation clearly explains the need for the requested equipment and the intended impact on your health and mobility.
4. Supporting Documents
In addition to your clinical record, the insurance company requires some supporting documents that support proving the medical necessity for the equipment. These supporting documents should also clearly explain your need.
5. Submit Your Claim
The process for submitting your claim can vary by care provider and insurance company. It’s important to contact your physician and/or insurance provider prior to submitting your claim to make sure you’re following the required process. This can help you avoid delays in the processing time.
When you are requesting reimbursement for durable medical equipment (DME) such as a wheelchair, the first step is to complete a Face-to-Face Evaluation (FFE) with your primary care provider. The Affordable Care Act (ACA) has set forth requirements for the completion of the FFE and they can be found in section 6407 of the ACA.
Your FFE must…
- Be conducted by a physician (MD, DO, OR DPM), physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS).
- Be an in-person appointment with you (the beneficiary) and your provider within six months prior to the date of the written order prior to delivery (WOPD).
- Document that you were evaluated and/or treated for a condition that supports the need for the equipment being ordered.
Insurance companies require a new face-to-face examination each time a new prescription is ordered.
Medicare requires a new prescription:
- For all claims for purchases or initial rentals
- When there is a change in the prescription for the accessory, supply, drug, etc.
- If a local coverage determination (LCD) requires periodic prescription renewal (i.e., policy requires a new prescription on a scheduled or periodic basis)
- When an item is replaced
- When there is a change in supplier (i.e., where you purchase your equipment)
Broda Tip: We recommend that your FFE documentation include dates of treatment(s), name of condition(s), and result of treatment relative to the need for the DME/MAE. The FFE must be completed on or before the date of the written order/prescription and may be no older than 6 months prior to the prescription date.
After your FFE, your provider will write you a prescription or detailed written order for the requested DME/MAE. This prescription must be sent to the medical equipment supplier BEFORE the item is delivered.
Your provider must include the following elements in the prescription:
- Beneficiary’s name
- Physician’s name
- Date of the order and the start date (if the start date is different from the date of the order)
- Detailed description of the item(s) for which you are requesting funding
- Your prescribing practitioner’s National Provider Identifier (NPI) number
- Your practitioner’s signature
- The date the order was signed
Broda Tip: The detailed written order or prescription cannot be written prior to your Face-to-Face Examination. Doing so may result in the claim being denied.
Clinical Record Documentation
In addition, your insurance company will review your clinical record to make sure it matches the needs stated in your claim.
Medicare, for example, will provide coverage for MAE if the equipment is reasonable and necessary for beneficiaries who have personal mobility deficit sufficient to impair their performance of mobility-related activities of daily living (MRADLs). For example, MRADLs could include toileting, feeding, dressing, grooming, and bathing in customary locations within the home.
Your documentation should clearly identify…
- The history of events that have taken place leading to the request of the MAE
- The mobility deficit that the MAE will correct
- All treatments provided that did not successfully eliminate the need for MAE
- All other MAE (walker, cane, crutch) used. The documentation must explain specifically why they did not meet the patients’ needs
- That the beneficiary lives in an environment that allows for safe adequate use of the MAE
- That the beneficiary or caregiver is capable of safely using/operating the requested MAE
Broda Tip: The list above is not exhaustive. Some insurance providers may require other criteria. You may need additional clinical documentation to prove medical necessity. During the review process, the following information will need to be present and clearly identifiable in the clinical record.
Please be sure to review the National Coverage Determination for Mobility Assistive Equipment policy in its entirety.
For a full list of Medicare considerations, visit Medicare’s National Coverage Determination (NCD) for Mobility Assistive Equipment (MAE) 280.3 policy.
All insurance providers require supporting documentation that proves medical necessity and contains more detail as to the beneficiary’s need for the requested equipment.
Documentation could include the following:
- Standard Written Order (SWO)
- Anatomical Assessment Form
- Case Evaluation Form for an equipment trial
- Beneficiary Authorization
- Continued Need
- Continued Use
- Home Assessment
- Proof of Delivery (POD)
Use this helpful checklist from Nordian Health Care Solutions for a complete list of documents to compile.
While filling out documentation for Medicare, be sure you are aware of the applicable coding of the item you’re requesting. The Healthcare Common Procedure Coding System (HCPCS) categorizes equipment that is eligible for reimbursement. If you’re not sure which HCPCS code applies to your Broda wheelchair, cushion, or accessory, your Broda representative can assist you.
Broda Tip: It is important to make copies of all required documents requested during this process. Maintaining copies of documents can save you valuable time if documents are requested again.
Submit Your Claim
Once you’ve completed all the steps above, you are ready to submit your claim. We recommend the following process:
- Make copies of ALL documents and maintain them for your records.
- Write a simple cover letter that explains the reason for your submission, including your contact information.
- Contact the provider or insurance company to whom you will submit your claim.
- Verify that you have all the required documents (Obtain a copy of a checklist from your insurance provider, if available.)
- Verify the insurance company’s mailing address and preferred method of claim delivery.
- Mail ALL original signed documents to your insurance provider. If you send copies, it may delay the claim processing.
- Obtain a tracking number for your package to ensure appropriate delivery.
- Follow up with your insurance provider to ensure they received your submission. Be sure to ask for a file number if one is available.
Broda Tip: If a PO Box is given as the delivery address, remember that FedEx and UPS do not deliver to PO Boxes. If you intend to send your package via FedEx or UPS, ask for a physical address that can be used for delivery.
Use the following clinical tools to provide support documentation for your medical need.
- Anatomical Assessment Form
- Bariatric Anatomical Assessment Form (for users over 350 lbs.)
- Case Evaluation Form
Q: Who submits the insurance “claim” or “bill” for the wheelchair?
A: Most commonly, the equipment supplier would be the one to complete and submit the paperwork. However, it may be the responsibility of the patient and/or the patient’s family, depending on how the equipment is obtained. We recommend that the individual requesting the chair clarify the billing process prior to obtaining the chair. Social workers, doctor’s offices, and insurance provider customer support are excellent resources to help if you are confused about how to submit a claim.
Q: What questions should I ask my insurance provider?
A: When contacting your insurance provider, it’s a good idea to ask the following questions:
- Can you provide me with a copy of your guidelines for determination of coverage?
- Is there a checklist for documentation required to process/submit a claim?
- What is the best number to call if I have any further questions?
Q: What information should I prepare before contacting my insurance provider with questions?
A: When contacting an insurance provider of any type you will need the following information to complete the call:
- Recipient’s full name as listed on the insurance card
- Recipients date of birth (Month/Date/Year)
- Recipient’s complete home address
- Recipient’s Social Security Number (This is usually requested to ensure they are looking at the appropriate recipient’s policy/coverage)
- Recipients Policy Number, Group ID, or Member ID. These descriptors can vary by provider, however, they are generally found on the front of the card
- Claims address and contact number (generally located on the back of the insurance card)
- If the beneficiary has both primary and secondary insurance that you will be utilizing for reimbursement of the equipment, it is important that you mention this on the call. It may change the process for submitting your claim.
When requesting information regarding coverage for DME/MAE (i.e., a wheelchair) you may also need the following information:
- Referring physician’s name and contact information
- ICD 9/10 Code(s) associated with the need for the equipment
- A copy of the physician’s order. Insurance companies often request this information. However, if you do not have it on hand, you can simply explain that you are in the beginning stages of completing this process. Doing so should eliminate any further questions regarding the physician’s order.
Broda is Here to Help with Insurance Claims
In short, getting insurance to pay or contribute to the purchase of medical equipment is not an easy task. If you have questions about how paying for a wheelchair will work for you, contact your insurance carrier for more information. Above all, your insurance company will be your best resource to prepare for the claims process. If you need help with ordering, documentation, configurations, or wheelchair fittings, our Broda support team is available to guide you through the process.
For more information, please reference:
- National Coverage Determination (NCD) for Mobility Assistive Equipment (MAE) (280.3) https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=219&ncdver=2&bc=AAAAgAAAAAAAA
- Noridian Documentation Checklist https://med.noridianmedicare.com/documents/2230715/26734435/Documentation+Checklist+-+Manual+Wheelchairs+%28MWC%29
- Affordable Care Act Face to Face Requirements
- Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
- Medicare Program Integrity Manual Chapter 5 – Items and Services Having Special DME Review Considerations
- CMS Manual Systems Pub. 100-04 Medicare Claims Processing Transmittal https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R574CP.pdf