Contract Type: DME (Durable Medical Equipment)

The contractor and contractor staff that provide services described in this chapter also must comply with Chapters 1–3 of the VR Standards for Providers manual.

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8.1 Overview of Durable Medical Equipment

This chapter applies to contracted durable medical equipment (DME) purchased for Vocational Rehabilitation (VR) customers.

VR purchases the following on a contract basis, including parts and accessories:

  • Rehabilitation or hospital beds;
  • Manual and power wheelchairs;
  • Bathroom assistive devices;
  • Patient lifts (manual or power);
  • Seating and positioning systems;
  • Scooters;
  • Continuous Positive Airway Pressure (CPAP) machine; and
  • Bilevel Positive Airway Pressure (BiPAP) machine.

Durable medical equipment (DME) may be purchased or rented from a noncontracted provider when the cost:

  • is less than the available contract rate; and
  • does not exceed the rates listed in VR's Maximum Affordable Payment Schedule (MAPS).

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8.2 Qualifications

A contract with the Texas Workforce Commission is required to provide the goods listed in 8.1 Overview of Durable Medical Equipment.

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8.3 Process and Procedure

VR staff provides the contractor with a copy of the recommendations for the prescriptions and equipment to be purchased.

The contractor determines the specific equipment needed based on both the customer's prescription and the recommendation made by the VR counselor.

The contractor provides the VR counselor with a cost estimate that includes the:

  • manufacturer's suggested retail price (MSRP) minus the established 18 percent discount;
  • comparable benefits submission, comparable benefits response, and explanation of benefits (EOB);
  • item number and description, matched with the appropriate codes from the Healthcare Common Procedure Coding System (HCPCS); and
  • anticipated delivery date.

VR staff issues a service authorization, with the approved estimated cost, to confirm that the purchase is approved. Purchase is not authorized until the contractor receives a service authorization from VR.

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8.4 Outcomes Required for Payment

For the contractor to receive payment, the contractor:

  • provides new (unused and not refurbished) DME as specified on a VR service authorization at the rate established in 8.5 Methodology for Payment;
  • delivers the goods to the specified address within 45 days of the service authorization, on the date and time mutually agreed upon by the counselor, customer, and contractor; and
  • delivers the goods in an assembled and fully functional state, including adaptations necessary to meet the individual needs of the VR customer as detailed on the service authorization and on the approved specification sheet provided by the contractor.

The contractor must submit an invoice for payment that must comply with the requirements explained in Chapter 3: Basic Standards.

The contracted DME provider must provide the following:

  • The item numbers and descriptions matched with the appropriate Healthcare Common Procedure Coding System (HCPCS) codes;
  • MSRP on the manufacturer's price list or the price shown on the order form (the price being billed must be at least the manufacturer's price minus the established 18 percent)
  • A copy of the customer's explanation of benefits (EOB) for all primary and secondary payers
  • An invoice with the service authorization number, customer's name, customer's case identification (ID) number, VR counselor's name, and date that the service was provided

VR staff is authorized to pay the provider for the entire functional unit upon verification that the equipment was delivered and all the documentation listed above was received.

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8.5 Methodology for Payment

Contractors agree to provide the contracted durable medical equipment (DME), listed in 8.1 Overview of Durable Medical Equipment at the established 18 percent discount from the manufacturer's suggested retail price (MSRP) for the entire functional unit.

TWC-VR is the payer of last resort. After the customer's primary and/or secondary benefit coverage has been applied, VR pays the contractor an amount equal to the copayment, coinsurance, or deductible due. VR does not pay more than the amount allowed by the customer's insurance or more than the rate specified in the VR contract, whichever is less.

Contracted DME that is vocationally necessary, but that is declined coverage by the customer's primary and/or secondary benefit coverage, is paid at the rate specified in the VR contract only when a service authorization has been issued by VR prior to the purchase.

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8.6 Additional Contractor Responsibilities

8.6.1 Maintenance and Warranty

The contractor gives the VR customer written instructions on how to operate and maintain the purchased equipment.

Based on the product type and the manufacturer's warranty, the contractor provides preventive maintenance at no additional cost to VR:

  • at the end of the sixth and 12th months of operation, or when the contractor is notified; and
  • within three days of notification by VR, at the customer's home or other address specified by VR.

8.6.2 Products Returned

If goods or equipment purchased with VR funds are subsequently returned to the contractor, or exchanged or replaced by the contractor, the contractor must notify the VR office in writing.

The notice must include:

  • a description of the item returned;
  • the date the item was returned;
  • the reason for the return;
  • the amount of credit due, if any;
  • the customer's name;
  • the case ID number; and
  • any subsequent actions that were taken (exchanged or replaced by the contractor).

If the item or equipment being returned has a different price or is substantially different from the original item or equipment, then VR will issue a replacement service authorization for the new item or equipment.

When a refund is due, the contractor must by the 15th of each month send a check for the total credit accumulated during the previous calendar month. The payment must be accompanied by supporting documentation and/or credit invoices for each transaction or item for which the credit reimbursement is issued. The supporting documentation and/or credit invoices must include the service authorization number and the customer's case ID number.

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