Medicare & Insurance BillingCoverage, network participation, and billing eligibility are verified for each patient and product.
§ 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. Contact Continental Medical before ordering so current supplier enrollment, network participation, documentation, and product eligibility can be verified.
Medically Necessary
Equipment prescribed by your treating physician with a qualifying diagnosis.
Plan Cost Sharing
Deductibles, coinsurance, and approved amounts vary by plan and coverage year.
Eligibility Review
Supplier enrollment, network status, and item coverage must be confirmed before delivery.
Documentation Support
Our team can explain the documentation and prior-authorization steps that apply to your order.
§ 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 | Current plan-year amount | Confirm the current amount with Medicare or your plan before ordering |
| Medicare Advantage | Varies by plan | Your plan may have different cost-sharing terms |
| Medigap / Supplement | May cover some co-insurance | Confirm coordination and submission responsibilities with the plan and supplier |
Rental vs. Purchase: Some plans treat certain equipment as rentals rather than purchases. Confirm the current arrangement, duration, ownership terms, and supplier eligibility before accepting 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.
Coverage and supplier eligibility are reviewed
The team confirms whether Continental Medical can serve the plan, location, and requested item before an order proceeds.
Prior Authorization (when required)
If the order can be accepted, the team explains the applicable prior-authorization process and expected timing.
Delivery and product information
For accepted orders, delivery options, available product instructions, and required delivery documentation are confirmed before fulfillment.
The claim follows the confirmed billing arrangement
Before delivery, the team explains whether the order will be billed to a payer or handled as a private-pay purchase.
Review payer notices when applicable
If Medicare or another payer is billed under the confirmed arrangement, review any notice it sends showing coverage decisions and member responsibility.
You receive the applicable balance information
Any deductible, coinsurance, non-covered amount, or private-pay balance is explained under the confirmed billing arrangement.
§ 06–08 — TennCare, Commercial Insurance & Cash Pay
TennCare / Medicaid
- Participation varies by managed-care organization, product, and service location
- Contact us with the member and plan information before placing an order
- Prior authorization and documentation may be required
- The plan determines coverage and member cost sharing
Commercial Insurance
- Network participation varies by carrier, plan, product, and state
- Contact us to confirm current in-network status for your specific plan
- Benefits and prior-authorization requirements must be verified before delivery
- The payer determines coverage and final member responsibility
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
- Private-pay purchases are not represented as eligible for later insurance reimbursement
§ 09 — Advance Beneficiary Notice (ABN)
Under some Medicare arrangements, a supplier may provide an Advance Beneficiary Notice when it expects Medicare may not cover an item. Read the notice carefully and confirm the current options, estimated cost, and appeal rights before deciding.
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 and do not proceed with the order.
Appeal rights and deadlines are stated on the payer's current notice. Follow that notice and contact the payer or qualified adviser before the listed deadline.
§ 10 — Medicare Appeals — Five-Level Process
| Level | Process | File By | Decision Time |
|---|---|---|---|
| Level 1 | Initial administrative review | See current denial notice | Varies |
| Level 2 | Independent reconsideration | See current decision notice | Varies |
| Level 3 | Administrative hearing, when eligible | See current decision notice | Varies |
| Level 4 | Appeals council review, when eligible | See current decision notice | Varies |
| Level 5 | Federal court review, when eligible | See current decision notice | Varies |
If you receive a Medicare denial, call us at (931) 444-3335. Ask which order and delivery records are available for your appeal.
Frequently Asked Questions
Do I need to call Medicare myself?
Contact Continental Medical first. The team will explain whether the order can be accepted and which verification, documentation, and payer steps apply.
How long does it take to get equipment after my doctor sends a referral?
Timing depends on inventory, documentation, authorization, destination, and supplier requirements. An estimate is provided after the order requirements are reviewed.
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?
Return and replacement options depend on the item, claim status, supplier rules, and reason for the request. Contact both the payer and Continental Medical before sending equipment back.
What if I have both Medicare and Medicaid (dual eligible)?
Coordination of benefits and cost sharing depend on current eligibility and plan rules. Contact both plans and Continental Medical before ordering.
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 →