§ 01 — Medicare Part B — DME Coverage Basics
Medicare Part B covers Durable Medical Equipment (DME) when it is medically necessary, prescribed by your doctor, and ordered from a Medicare-enrolled supplier. Continental Medical is a Medicare-enrolled DMEPOS supplier. We bill Medicare directly on your behalf — you do not need to pay upfront or contact Medicare yourself.
Medically Necessary
Equipment prescribed by your treating physician with a qualifying diagnosis.
80/20 Cost Share
Medicare pays 80% of the approved amount after your annual Part B deductible ($257 in 2025).
Assignment Accepted
We accept Medicare assignment on all covered items — no surprise balance billing.
We Handle Paperwork
We process eligibility, prior authorizations, and claims filing at no charge to you.
§ 02 — What Medicare Part B Covers
The following product categories are covered under Medicare Part B when medical necessity criteria are met. Coverage always requires a signed physician order and a qualifying ICD-10 diagnosis code.
| Product Category | HCPCS Range | Coverage Condition |
|---|---|---|
| Manual Wheelchairs (standard, lightweight) | K0001–K0004 | Unable to ambulate; physician order required; face-to-face exam within 6 months for K0003–K0004 |
| Transport Chairs | K0001 | Mobility limitation documented; cannot self-propel |
| Rollators / Walkers | E0130–E0149 | Ambulation limitation; physician order; cognitive ability to safely use |
| Crutches | E0110–E0116 | Physician order; medically necessary for ambulation |
| Hospital / Homecare Beds | E0250–E0304 | Medical necessity: congestive heart failure, COPD, orthopedic condition; head elevation required |
| Patient Lifts (hydraulic/electric) | E0621, E0635 | Unable to transfer; caregiver needed; documented in plan of care |
| Commode Chairs | E0163–E0168 | Unable to ambulate to bathroom; confined to room |
| Bath / Shower Seats | E0240–E0249 | Balance/safety impairment; physician order |
| Raised Toilet Seats | E0244 | Lower extremity or mobility impairment |
| Prefabricated Orthotics | L0100–L4631 | Physician prescription; diagnosis-specific; off-the-shelf fit |
| TENS Units | E0720–E0749 | Chronic intractable pain; physician order; trial period documentation |
| Diabetic Testing Supplies | A4253, A4256 | Diabetes diagnosis; physician order; insulin or non-insulin dependent per CMS policy |
§ 03 — What You Need to Qualify for Medicare-Covered DME
| Document | Description |
|---|---|
| Written Physician Order | Signed order from your treating physician, NP, or PA specifying exact equipment, quantity, length of need, diagnosis code, and date. Must be dated. |
| ICD-10 Diagnosis Code | Medical condition code supporting necessity; must meet Medicare's Local Coverage Determination (LCD) criteria for the requested item. |
| Face-to-Face Examination | Required for many items (especially K0003–K0004 wheelchairs). Written documentation of clinical evaluation within 6 months before ordering. |
| Clinical Notes (if required) | Recent office notes, PT/OT records, or hospital records demonstrating medical necessity. Recommended for all Medicare referrals. |
| Medicare Card | Red, white, and blue Medicare card (or Medicare Advantage plan card) with your Medicare Beneficiary Identifier (MBI). |
| Homebound Status (some items) | Some equipment requires documentation that leaving your home requires considerable effort and assistance. |
§ 04 — Your Cost Share — What Medicare Pays vs. What You Pay
| Who Pays | Amount | Notes |
|---|---|---|
| Medicare Part B | 80% of Medicare-approved amount | After patient meets annual Part B deductible |
| You (co-insurance) | 20% of Medicare-approved amount | Medigap/supplemental policy may cover this amount |
| Annual Deductible | $257 (Part B, 2025) | Applied once per year across all Part B services before Medicare pays |
| Medicare Advantage | Varies by plan | Your plan may have different cost-sharing terms |
| Medigap / Supplement | May cover the 20% co-insurance | We will bill your supplemental insurer after Medicare pays if you provide the information |
Rental vs. Purchase: Some items (homecare beds, patient lifts) are initially rented by Medicare with monthly payments until the capped rental period (usually 13 months), after which ownership transfers to you. We explain which arrangement applies to each item before delivery.
§ 05 — How the Medicare Billing Process Works
Your doctor sends us a referral and written order
Via fax (931) 225-4944, phone (931) 444-3335, or online referral form. Must include diagnosis, equipment needed, and physician signature.
We verify your Medicare eligibility and coverage
We check enrollment status, confirm the item is covered under your plan, and verify the diagnosis meets Local Coverage Determination (LCD) criteria.
Prior Authorization (when required)
We submit a PA request to your DME MAC for certain items on the CMS Required Prior Authorization List (including some wheelchairs and orthotics). CMS processes within 7 calendar days.
Delivery and patient instruction
Equipment is delivered to your home with written and verbal instructions. You sign a Proof of Delivery form, as required by Medicare Supplier Standard 12.
We submit the claim to Medicare
After delivery and signature, we file your Medicare claim electronically. Claims typically process within 14–30 calendar days. You do not need to take any action.
You receive a Medicare Summary Notice (MSN)
About 3–4 months after delivery, you will receive an MSN showing what was billed, what Medicare approved, what Medicare paid, and what you owe. Review it carefully.
We bill you for your co-insurance (20%)
After Medicare pays 80%, we send you a statement for your 20% share. We can also bill your Medigap/supplemental insurer if you provide that information. Payment accepted by card, ACH, or check.
§ 06–08 — TennCare, Commercial Insurance & Cash Pay
TennCare / Medicaid
- TennCare (Tennessee's Medicaid) accepted for eligible DMEPOS items
- Administered by BlueCare Tennessee, UnitedHealthcare Community Plan, and Cigna-HealthSpring
- Most items require prior authorization — we submit PA on your behalf (1–5 business days)
- TennCare members typically have little or no cost-sharing for covered DME
Commercial Insurance
- Works with most major carriers: Blue Cross, Humana, Aetna, UnitedHealth, and others
- Coverage varies by plan — we verify benefits and obtain required PAs before delivery
- Contact us to confirm if Continental Medical is in-network with your specific plan
- We explain your expected out-of-pocket cost before delivery
Cash / Private Pay
- All catalog products available for cash/private pay at listed prices
- No insurance or physician order required for most standard DME when paying out of pocket
- Itemized quotes available via our Quote Request system
- May assist with retroactive Medicare billing if proper documentation is later obtained
§ 09 — Advance Beneficiary Notice (ABN)
An ABN is provided to you when Medicare is likely to deny payment due to medical necessity concerns or coverage criteria not being met. It explains why Medicare may not pay, your options, and the estimated cost if Medicare denies the claim.
Request the item and have Medicare billed anyway. If denied, you are responsible for the full cost but retain the right to appeal.
Request the item but do not bill Medicare. You pay the full cash price directly.
Decline the item. Continental Medical will not provide it.
You always have the right to appeal a Medicare denial. You have 120 days from the denial notice to file a Redetermination request. We can help you understand the appeals process.
§ 10 — Medicare Appeals — Five-Level Process
| Level | Process | File By | Decision Time |
|---|---|---|---|
| Level 1 | Redetermination with DME MAC | 120 days from denial | 60 days |
| Level 2 | Reconsideration with Qualified Independent Contractor (QIC) | 180 days from Level 1 decision | 60 days |
| Level 3 | ALJ Hearing (amount ≥ $230 in 2025) | 60 days from Level 2 decision | 90 days |
| Level 4 | Medicare Appeals Council review | 60 days from Level 3 decision | 90 days |
| Level 5 | Federal District Court (amount ≥ $1,870 in 2025) | 60 days from Level 4 decision | Varies |
If you receive a Medicare denial, call us at (931) 444-3335. We will provide copies of delivery documentation and your original physician order to support your appeal.
Frequently Asked Questions
Do I need to call Medicare myself?
No. Continental Medical handles all Medicare billing and verification. You only need to ensure your doctor sends the required order and documentation.
How long does it take to get equipment after my doctor sends a referral?
In-stock items without a prior authorization requirement: 1–3 business days. Items requiring prior authorization: 7–14 business days after documentation is received. We provide an estimated timeline when your order is processed.
What if my doctor won't fill out the paperwork?
Our provider team can send your doctor a documentation checklist and pre-formatted order letter to ease the process. Call (931) 444-3335 for assistance.
Can I return Medicare-covered equipment?
Returns of Medicare-billed DMEPOS are subject to strict federal rules. Once a claim has been submitted and paid by Medicare, the item generally cannot be returned. If there is a problem with your equipment, call us immediately — we may be able to replace a defective item.
What if I have both Medicare and Medicaid (dual eligible)?
Medicare pays first; TennCare may pay some or all of your Medicare cost-sharing (20% co-insurance and deductible). We handle billing for both automatically.
Questions about your coverage or billing?
Call us at (931) 444-3335 Mon–Fri 9:30 AM – 3:30 PM CT, or email info@continentalmedical.net.
For providers: Submit a referral online →