BOC-CDME key terms

A standardized form, signed by the treating physician, that documents why a specific item of durable medical equipment is medically required for a patient and supports the claim submitted to the payer.

The determination that a piece of equipment or service is reasonable and required to treat a patient's condition, based on clinical records rather than convenience or patient preference alone.

A notice given to a Medicare beneficiary before providing an item or service that may not be covered, so the patient can choose to accept and pay for it personally if coverage is denied.

The portion of a covered or noncovered charge that a patient is personally responsible for paying, such as coinsurance, deductibles, or items delivered under a signed advance notice of noncoverage.

The percentage share of an allowed charge that a patient pays after the deductible is met, with the insurer or plan paying the remaining percentage.

A fixed amount a patient must pay out of pocket for covered services before an insurer or plan begins paying its share of the allowed charges.

A statement from an insurer summarizing submitted claims, allowed amounts, payments made, and the patient's financial responsibility, used by suppliers to reconcile accounts and answer billing questions.

An electronic or paper report from a payer that lists claims processed, amounts paid or denied, and adjustment reason codes, allowing a supplier to post payments and manage denials accurately.

A payer's decision not to pay a submitted claim, often due to missing documentation, ineligible coverage criteria, coding errors, or timely filing violations, requiring review and possible appeal.

A formal request that a payer reconsider a denied claim, supported by clinical records and a written rationale, following the payer's specified levels and deadlines.

Clinical notes and orders in the patient's medical record that describe the diagnosis, functional limitations, and equipment needs, forming the evidentiary basis for reimbursement.

The specific conditions a payer requires a patient to meet before an item or service is reimbursable, such as a diagnosis, functional deficit, or prior failed treatment.

A payer's advance approval of an item or service before it is delivered, confirming that coverage criteria are met so the supplier can be paid.

Equipment that can withstand repeated use, is primarily used for a medical purpose, is not useful in the absence of illness or injury, and is appropriate for use in the home.

A wheelchair or scooter propelled by a motor and battery rather than by the user's own effort, typically requiring a face-to-face evaluation and detailed mobility documentation.

A wheelchair propelled by the user's arms or by an attendant, selected based on the patient's strength, endurance, home environment, and seating needs.

The selection and adjustment of cushions, backs, and supports to maintain skin integrity, postural alignment, and comfort for a patient who uses a wheelchair.

A cushion designed to redistribute pressure away from bony areas for a patient at risk of skin breakdown, often requiring documentation of the risk level to support coverage.

The decision whether to bill equipment as a recurring monthly rental or as a one-time purchase, governed by payer rules, expected duration of need, and the item's classification.

A payment method in which a payer reimburses an item monthly for a limited period, after which the beneficiary may retain the equipment with no further rental payments.

A device that draws in room air, removes nitrogen, and delivers concentrated oxygen to a patient with a documented need for supplemental oxygen therapy at home.

A device that delivers pressurized air through a mask to keep the upper airway open during sleep for patients with diagnosed obstructive sleep apnea.

Objective usage records downloaded from a device such as a CPAP machine, used to show that the patient is using the equipment as prescribed and to support continued coverage.

The process of tracking stock levels, reorder points, serial numbers, and equipment location so that a supplier can meet patient needs without excess cost or stockouts.

Recording the unique identifier of each device so a supplier can trace recalls, warranty claims, maintenance history, and proof of delivery for a specific patient.

Documentation, such as a signed receipt, confirming that equipment was delivered to the patient, the date of delivery, and the items and quantities provided.

The operational step of transporting equipment to a patient's home, assembling it, and instructing the patient or caregiver on safe and correct use.

A report grouping unpaid claims by how long they have been outstanding, helping a supplier identify slow payers, denials, and collection priorities.

The end-to-end process of verifying eligibility, obtaining authorizations, billing, collecting, and appealing denials to convert services into collected revenue.

Confirming a patient's insurance coverage, benefits, and any limitations before delivering equipment, to reduce denials and unexpected patient balances.

A federal regulation governing how protected health information may be used, disclosed, and safeguarded by health care providers and their business associates.

Individually identifiable health information, such as a patient's name combined with a diagnosis or equipment order, that must be protected from unauthorized access or disclosure.

The principle that only the least amount of protected health information needed for a given purpose should be accessed, used, or shared with others.

A federal law prohibiting knowingly offering or receiving anything of value to induce referrals of items or services payable by federal health care programs.

A federal law that prohibits physician self-referral of certain designated health services to an entity in which the physician or an immediate family member has a financial interest, absent an exception.

A federal law imposing liability on persons or entities that knowingly submit or cause the submission of false or fraudulent claims to government payers.

An organization's structured policies, training, auditing, and reporting mechanisms designed to prevent, detect, and correct violations of laws and payer requirements.

Teaching a patient or caregiver how to safely use, maintain, and troubleshoot equipment, including when to seek help, delivered in language they understand.

Communication among the supplier, physician, therapist, and caregiver to ensure equipment needs, delivery timing, and follow-up are aligned with the patient's plan of care.