If you have Resupply programs available for your patients, creating Resupply Payer Rules will help streamline your Resupply order workflow and reduce denials for frequency limitations.

The frequency of a payer's reimbursement for supplies will vary according to the product dispensed. Many payers follow Medicare's replacement schedule, but it's always recommended you verify coverage criteria with your payer.

By creating a Resupply rule, you can tell the system how often specific HCPCs can be supplied. You can make this rule Payer-specific and/or Plan-specific.

If a Resupply rule is defined, it will reflect the eligibility in the patient's Resupply Program for those HCPCs. Additionally, if an order is created with an item that exceeds the frequency eligibility for the patient, that order will automatically be tagged with "resupply limit". This tells the user that further review must be taken.

To create a Resupply rule for a specific Payer, navigate to the Payer queue in Management settings:

Management > Billing Setup > Payers

Click on the specific Payer you're creating the Resupply rule for. This will bring you to a variety of settings for this Payer. Click on the Rules tab to manage their Payer rules.

Under the Payer Rules, select Resupply.

From this screen, you will see any existing Resupply rules for this Payer. You can also create a new Resupply rule. You have the option of creating a product-specific rule or a generic rule.

When adding a Product-specific rule, you'll be prompted to select items from your Product Catalog first.

You will now be prompted to enter the HCPCS code(s). You can select multiple HCPCS codes and create a single rule if they require the same frequency.

Next, you'll add the Quantity and Resupply Period (or frequency of the replacement).

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As an example you may create a rule for the following products/HCPCS:

And the Resupply Period of Every 1 Month.

To create the rule, enter each HCPCS into the search field, one by one. In this example, we are creating a single rule for multiple HCPCS with the same frequency. To add all the relevant HCPCS codes to this rule, enter a HCPCS, then click the blue plus sign to add, and then enter the next HCPCS.

Once you have added all your resupply rules be sure to select Save.