Medicare and Spinlife
Need to submit Medicare-related forms to SpinLife? Please fax to: 1-866-716-3278
is an authorized Medicare provider and we are happy to assist you in obtaining
reimbursement from Medicare for lift chairs, rolling walkers and wheelchair
cushions. Items eligible for Medicare reimbursement are marked with this icon:
Please note: SpinLife does not provide Courtesy Billing for Medicaid.
Please take the time to look through common questions you might have about Medicare billing below. If you need additional help, please call our Medicare specialists at 1-800-850-0335.
- How does Medicare "courtesy billing" work?
- How much will I be reimbursed through Medicare?
- Is Courtesy Billing for mobility scooters available in my area?
- How does the reimbursement process work?
- Can SpinLife bill HMO Medicare Advantage Plans like Secure Horizons or Humana?
- What are the reimbursement criteria for mobility scooters?
- What are the reimbursement criteria for lift chairs?
- What are the reimbursement criteria for wheelchair cushions?
- Can SpinLife bill Medicare for a power wheelchair?
- Can SpinLife bill Medicare for a manual wheelchair, hospital bed, or patient lift?
- How can I find out if my physician has a valid NPI and PECOS enrollment?
- Can SpinLife bill Medicaid for my items?
How does Medicare "courtesy billing" work?
We understand that the process of submitting claims to Medicare can be difficult and time consuming. To help make the process easier, SpinLife offers what is known as Courtesy Billing. This means that after you purchase an eligible product from SpinLife and request at checkout that we courtesy bill Medicare, we handle all of the documentation required to submit a claim to Medicare on your behalf. If your claim is approved by Medicare, they will reimburse you directly for their portion of your claim.
Please note the following important information about Medicare Courtesy billing:
- In order for us to courtesy bill, Medicare must be your primary insurance
- We are unable to courtesy bill any Medicare Advantage programs
- We are unable to courtesy bill Medicare if the beneficiary is in a nursing home, skilled nursing facility, home health facility or hospice facility
- We are able to courtesy bill Medicare for beneficiaries in assisted living facilities; we will need to know that the beneficiary is in an assisted living facility because these claims are filed differently
How much will I be reimbursed through Medicare?
Medicare assigns every product that is eligible for reimbursement what is called an "allowable amount". The allowable amount is the maximum amount that Medicare will consider as the total price of the item. The allowable amount for each item varies slightly by state. Medicare will pay 80% of the allowable amount or 80% of the cost of the item from SpinLife, whichever is less. The other 20%, or copay, is the beneficiary’s responsibility.
Because SpinLife’s prices are generally well below the Medicare allowable amount for eligible products, your 20% copay will likely be less than what it would be if you purchased from a local medical equipment supplier. This could mean significant savings on your 20% copay. Here are allowable amounts for items commonly purchased on SpinLife:
· Lift Chair Mechanisms (HCPCS Code E0627):
The allowable range is between $250-$300. View a state-by-state reimbursement chart.
· Wheelchair cushions that provide skin protection and/or positioning (HCPCS Code E2605-E2622):
The allowable ranges from $250 - $350 for standard sizes, depending on the specific cushion you choose.
Please note the following important information about Medicare reimbursement amounts:
· Any applicable deductibles must be met before Medicare will reimburse you for their portion of the allowable amount on an approved claim.
· While we can't guarantee Medicare reimbursement, we can promise that we’ll work with you to ensure that claims will be filed accurately and completely.
Is Courtesy Billing for scooters available in my area?
Medicare has instituted complex rules regarding the coverage process for mobility scooters. Therefore, SpinLife no longer offers the option of requesting Medicare Courtesy Billing for mobility scooters when ordering online. If after reading the reimbursement criteria listed below, you still feel that you have an eligible claim, please call and talk to a sales specialist to request Courtesy Billing.
Effective September 1, 2012, for residents of CA, FL, IL, MI, NY, NC and TX: The Centers for Medicare and Medicaid (CMS) implemented a Prior Authorization (PA) process for scooters for people with Fee-For-Service Medicare who reside in seven states with high populations of fraud- and error-prone providers. The PA process does not disqualify you from reimbursement; it just changes the procedure for billing and delivery. Therefore, if you live in these states we will not be able to ship your product until we send all the necessary paperwork to Medicare and they respond to us with the authorization to proceed. For more information, see "Fact Sheet: General Information" (PDF).
We are also unable to provide Courtesy Billing to Medicare if the beneficiary resides in a Competitive Bid Area (CBA). The ZIP codes included in each CBA are posted on the Competitive Bidding Implementation Contractor (CBIC) web site: http://dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home. Beginning July 1, 2013, over 90% of the population of the US will be included in a CBA, and SpinLife will no longer provide any Courtesy Billing for mobility scooters.
How does the reimbursement process work?
After purchasing a Medicare-eligible product and requesting that SpinLife bill Medicare on your behalf, we will work with you to complete the required documentation and submit your claim.
Here's the basic process:
Step 1:: We will send you the three documents listed below, which you must read and sign. You may provide your electronic signature online during the checkout process or via the Medicare email that you receive from SpinLife. You may also choose to print, sign and return these documents to SpinLife via fax or mail.
— Medicare Supplier Standards
— HIPAA Privacy Notice
— HIPAA Authorization Form
Step 2: We will ask you to submit the following information to SpinLife:
— The prescription from your physician for all Medicare eligible equipment. This prescription must have a date that is before the date your product is delivered.
— A copy of your Medicare Card, both front and back
— Your date of birth
— For lift chairs only, please have your physician fill out the Certificate of Medical Necessity (CMN) document, which we will provide. This document must be signed/dated within 30 days of the written RX date, and can be returned to SpinLife by either the physician's office or by you.
- For mobility scooters only, you will schedule a face-to-face Functional Mobility Examination with your physician. Full details of the process are provided in the Medicare packet which we will provide.
- For cushions only, the manufacturer name, model number, serial number and date of purchase of the wheelchair already on file with Medicare for which the cushion will be used
Step 3: After all information is received, including the information required by your physician, SpinLife will file your claim with Medicare within seven days.
Step 4: Medicare will process your claim. Medicare has between 45-60 days to respond to you regarding your claim and if your claim is approved, you will receive reimbursement directly from Medicare.
Important Note: SpinLife cannot provide Courtesy Billing for customers that have an HMO Medicare Advantage Plan as their primary coverage (such as Secure Horizons HMO or Humana HMO). An Advantage HMO is a Medicare replacement HMO program whose services have been enlisted to manage your Medicare coverage and benefits.
Can you bill HMO Medicare Advantage Plans like Secure Horizons or Humana?
SpinLife cannot provide Courtesy Billing for customers that have an HMO Medicare Advantage Plan as their primary coverage (such as Secure Horizons HMO or Humana HMO). An Advantage HMO is a Medicare replacement HMO program whose services have been enlisted to manage your Medicare coverage and benefits.
What is the reimbursement criteria for mobility scooters?
The beneficiary may qualify for reimbursement for a mobility scooter (also called power operated vehicles or POVs) if the following general criteria are met:
— Medicare will deny a scooter as not medically necessary when it is needed only for use outside the home. A scooter that is beneficial primarily in allowing the beneficiary to perform leisure or recreational activities, or to move about outside the home for activities such as shopping or traveling around the neighborhood will be denied as not medically necessary. Medicare will only cover a mobility scooter when the beneficiary meets the following strict criteria:
—The beneficiary must have a mobility limitation which prevents them from performing one or more mobility related activities of daily living in the home, including toileting, eating, bathing, and grooming.
— There cannot be other conditions that limit the beneficiary from performing mobility-related activities of daily living at home, such as significant impairments of cognition or judgment and/or vision. This only applies if these other conditions cannot be addressed through other means, including caregiver support.
— The beneficiary must demonstrate the capability and the willingness to consistently operate the device safely.
— A cane, walker, or manual wheelchair will not provide the necessary functional mobility for mobility related activities inside the home.
— The beneficiary’s environment must allow for the use of scooter in all areas where the mobility related activities of daily living are customarily performed.
— For a scooter, the beneficiary must have sufficient strength and postural stability to operate the scooter.
What is the reimbursement criteria for lift chairs?
Medicare only covers the seat-lift mechanism, but not the actual chair/furniture portion itself. The reimbursement amount is between $250-$300 depending on the state (view chart) in which the beneficiary is located if the coverage criteria are met. A lift chair is considered medically necessary if all of the following coverage criteria are met:
— The beneficiary must have severe arthritis of the hip or knee, or have a severe neuromuscular disease.
— The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the patient's condition.
— The patient must be completely incapable of standing up from a regular armchair or any chair in their home.
— Once standing, the patient must have the ability to walk, even if a cane, walker or other assistance is required. Medicare will not cover this item if the beneficiary has a wheelchair, scooter, or power wheelchair on file.
— By Medicare standards, the fact that a beneficiary has difficulty or is even incapable of getting up from a chair, particularly a low chair is not sufficient justification for a seat lift mechanism. Almost all beneficiaries who are capable of ambulating can get out of an ordinary chair, if the seat height is appropriate and the chair has arms.
— Medicare requires that the physician ordering the seat lift mechanism must be the attending physician or a consulting physician for the disease or condition resulting in the need for a seat lift.
What is the reimbursement criteria for wheelchair cushions?
For wheelchair cushions, the wheelchair for which the cushion will be used must already be on file with Medicare. When Courtesy Billing for the corresponding cushion, Medicare requires the manufacturer, model and the date of purchase of the wheelchair on file. If no wheelchair is on file with Medicare, a cushion and wheelchair can be billed at the same time. The beneficiary must also either have a current pressure sore or have a previous history of a pressure sore on record due to the fact that Medicare will not cover any preventative items. Documentation of positioning requirements and any other risk factors will also be taken into consideration and should be submitted to SpinLife with the prescription.
Can you bill Medicare for a power wheelchair?
SpinLife cannot provide Courtesy Billing to Medicare for power wheelchairs (also called power mobility devices) because Medicare only provides coverage for power wheelchairs on a rental basis, and SpinLife does not provide rental equipment. If you rent a power wheelchair from a local dealer, you will pay a monthly copay of 20% of the monthly rental amount. There is no guarantee that you will receive new equipment, nor can you specify a choice of the brand or model that you prefer. After 13 months of continuous rental, the item is then "purchased" for the beneficiary by Medicare and no additional copay is required.
Many consumers choose to purchase their own power chair to guarantee that they receive new product instead of used product, and that they get the exact product they want. Talk to one of our product specialists about finding the perfect new chair to meet your specific needs, and about our financing options. We currently offer 6 months with no payments and no interest through BillMeLater.
Can you bill Medicare for a manual wheelchair, hospital bed, or patient lift?
Ultra Lightweight K0005 Manual Wheelchairs are the only type of manual wheelchairs that products that will be purchased upfront by Medicare. If you choose to purchase your ultra-lightweight wheelchair from SpinLife, we will be happy to assist you in filing for Courtesy Billing with Medicare. When ordering or filling out a quote simply select “Courtesy Medicare Billing.” SpinLife will send you a packet of Medicare documents explaining the necessary steps to file with Medicare for reimbursement. SpinLife can send this packet to you electronically or by mail.
SpinLife only sells new equipment and does not provide rentals, therefore we are unable to bill Medicare for products that qualify as rental items. Standard wheelchairs, lightweight wheelchairs, hospital beds and patient lifts are considered rental items. They require a monthly copay of 20% of the monthly rental amount. After 13 months of continuous rental, the item is then “purchased” for the beneficiary and no additional copay is required.
Many consumers choose to purchase the items they need from SpinLife because our purchase price is often comparable to the 20% copay they would be required to pay over a 13 month rental period to a local dealer. Purchasing from SpinLife also guarantees that you will receive new items instead of used, and that you will get the exact product you want.
How can I find out if my physician has a valid NPI and PECOS enrollment?
Please note: Effective July 1, 2010, in order to be eligible for Medicare reimbursement on any durable medical equipment purchase, your prescribing physician must:
— Have a valid national provider identifier (NPI).
— Be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS).
If your prescribing physician does not have a valid NPI or PECOS enrollment, your claim will be denied. To view a list of physicians and non-physician practitioners who have a valid NPI and PECOS enrollment, you can visit this government website and download the PDF document titled Medicare Ordering and Referring File [PDF]. You can also contact your physician's office for this information.
Additional Information Required by Medicare
Warranty Information (Medicare requires that we provide this information)
Every product sold by our company carries a warranty which can range from 6 months to more than 5 years. SpinLife honors all manufacturer warranties, and will provide replacement parts, free of charge, for Medicare-covered equipment that is under warranty. In addition, an owner’s manual with warranty information will be provided to beneficiaries for all equipment where this manual is available.
Medicare Capped Rental (Medicare requires that we provide this information)
Capped Rental Items are items where Medicare will pay a monthly rental fee for a period not to exceed 13 months, after which the ownership of the equipment is transferred to the Medicare beneficiary and it is the beneficiary’s responsibility to arrange for any required equipment service or repair. Examples of this type of equipment include hospital beds, alternating pressure pads, air-fluidized beds, nebulizers, suction pumps, continuous airway pressure (CPAP) devices, patient lifts and trapeze bars.
Items Inexpensive or Routinely Purchased items Notification (Medicare requires that we provide this information)
Inexpensive or routinely purchased items include Lift Chair seat lift mechanisms, canes, walkers, crutches, commode chairs, low pressure and positioning equalization pads, home blood glucose monitors, pneumatic compressors (lymphedema pumps), bed side rails, and traction equipment. These items can be purchased or rented, although the total amount paid for monthly rentals cannot exceed the fee schedule purchase amount.
SpinLife does not provide rentals and does not provide most of these items with the exception of lift chair seat lift mechanisms.
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Can SpinLife bill Medicaid for my items?
Unfortunately, SpinLife cannot provide Courtesy Billing for Medicaid. We can only provide Courtesy Billing to Medicare or private insurance.