Name of Manual - Blue Cross and Blue Shield of Minnesota

Upgraded/Deluxe
Durable Medical
Equipment (DME)
DME Waiver
Requirement
DME Claims
Submissions
Commercial Business
Integrated Health Management
Participating durable medical equipment (DME) suppliers may bill
members for an equipment upgrade or deluxe charge if a waiver is
on file and the DME charges are billed correctly to Blue Cross. We
continue to reimburse for medically necessary standard DME.
Government Business
Participating durable medical equipment (DME) suppliers may bill
members for an equipment upgrade or deluxe charge if a waiver is
on file and the DME charges are billed correctly to Blue Cross.
Participating DME suppliers must obtain a signed, written waiver
from the member that includes the cost for the deluxe features or
upgrade. The waiver must also state the following:
the standard piece of equipment or least costly alternative
offered to the member,
the member is aware and agrees that Blue Cross will only pay
the standard allowance, and
the member will be responsible for the deluxe or upgrade
charge in addition to his or her contractual obligation.
This waiver must be kept on file at your office. If a precertification/authorization
are required for the item being provided,
please send the waiver form along with your request. For all
services that do not require a pre-certification/authorization, do
not send it to Blue Cross. We do, however, reserve the right to
see it.
Two lines of service must be billed. The first line will include the
DME HCPCS code and the standard charge for the equipment. The
second line must include the same DME HCPCS code with the -
GA modifier (waiver of liability statement on file) and the upgrade
or deluxe charge. For example:
E0202 -- $550.00 (standard charge that will be subject to
standard allowance and reductions)
E0202 GA -- $150.00 (deluxe/upgrade charge that will be
denied as member liability)
The -GA modifier must be submitted as the first modifier on the
second service line. Other applicable modifiers, such as -NU
(Purchase), should be submitted on the first service line.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-35