What is a Payer Rule?
Resupply
If you are supplying patients with ongoing disposable supplies creating resupply payer rules will help streamline your resupply order workflow and reduce denials for frequency limitations.
The frequency of when a payer may reimburse for supplies varies according to the product dispensed. Many payers do follow Medicares replacement schedule however it is 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 and or plan specific.
If a resupply rule is defined, it will reflect the eligibility in the patients resupply program for those HCPCS. In addition if an order is created with an item that exceeds the frequency eligibility for the patient, the order will automatically be tagged with "resupply limit" indicating to the user that further review must be taken.
To create a resupply rule, navigate to the payer for which you wish to create a rule under your management tab. Find the tab marked “Resupply” and select it.
Find “Add Rule” on the right and select it.
You will now be prompted to enter the HCPCS codes. You can select multiple HCPCS codes and create a single rule if they require the same frequency.
As an example you may create a rule for :
A7034 (CPAP nasal mask)
A7030 (CPAP full face mask)
A7037 (CPAP standard tubing)
A4604 (heated CPAP tubing)
Add a frequency rule of 1 (time) per 3 (months) Qty 1
To create the rule select the HCPCS into the search field and select each one.
Be sure to select the blue plus sign after each code you enter
Now you will need to add their frequency of replacement: How many times per how many days/weeks/months and how many of the item/quantity. The example below shows that the items are replaceable 1 time every 3 months and they can only receive 1 unit
In some cases payers allow you to provide patients with quarterly frequency of supplies.
As an example, lets say you can provide the patient a quantity of 6 items each every three months:
A7038 (CPAP disposable filters)
A7033(CPAP nasal pillow replacements)
A7032 (CPAP nasal cushion replacements)
Once you have added all your resupply rules be sure to select save on the bottom right.
