How to Bill Insurance for Out-Of-Pocket Medical Expenses

Posted by Aubrey Shelton on Oct 5, 2015 8:30:00 AM

According to the web site of the Center for Medicare and Medicaid Services (CMS), health care insurers process over 5 billion claims for payment in the United States each year. To accommodate for the high volume of requests, it was decided that a standardized coding system was essential to ensure the claims processing center proceeds in a well-ordered and uniform fashion. As a result HCPCS codes were developed to simplify medical billing. Since Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT codes, the Level II HCPCS codes were established for submitting claims for items such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside of a physician's office.

If an item has been assigned an HCPCS code, does this mean Medicare or Medicaid covers it? The answer unfortunately is, No.

Whether an item with a HCPCS code is covered under a particular state Medicaid program depends on whether the item meets the states definition of durable medical equipment, prosthetics, orthotics, or any other service covered in that state. However, we encourage all of our customers to follow these simple steps and apply to be reimbursed.

5 Easy Steps: How to Bill Insurance for Out-Of-Pocket Medical Expenses

The COPD Store would like to provide as much information to our customers as possible. One of the main questions we receive is; how should I bill my health Insurance for an “Out-of-Pocket” medical expense?

Although we cannot determine or guarantee that the policies and procedures for every single insurance company will follow these specific instructions but generally it is a good place to start.

Step 1: Reach Out to Your Insurance Company

Contact the member services department of your insurance company and ask the following questions:

  • “Do you allow subscribers to submit claims for medical expenses purchases out-of-pocket such as Oxygen or CPAP supplies you purchased through The COPD Store?”
  • “What type of form will they need you to use in order to submit your claim information?”
  • “Can I fax this claim back to you? What is your fax number?” or “What is your mailing address?”

(Some insurance companies will allow you to use a generic form called the Health Insurance Claim Form. You can download this form Here).

“Can you please verify with me the HCPCS codes, Diagnosis Codes and Tax ID numbers you would like me to enter on this form?” 

  • The COPD Store/1st Class Medical's Tax ID Number is 35.2409307
  • The COPD Store/1st Class Medical's HPI Number is 1538430616
  • COPD Store/1st Class Medical
  • 14 Inverness Dr. East
  • Ste B120
  • Englewood, CO 80112
  • Phone: 1.800.269.0726
  • Fax: 303-792-0711

Physician Diagnosis Code

Insurance companies require you to provide a code associated with your specific medical diagnosis. The diagnosis code for Chronic obstructive pulmonary disease (COPD) includes chronic bronchitis (ICD-9 codes 490-491), Obstructive Sleep Apnea is ICD-9 code 327.23, emphysema (ICD-9 code 492), bronchiectasis (ICD-9 code 494), and chronic airway obstruction (ICD-9 code 496). These diseases are commonly characterized by irreversible airflow limitation. Some authorities include asthma (ICD-9 code 493) and hypersensitivity pneumonitis (ICD-9 code 4950.To ensure that you have the correct code for your diagnosis, contact your physician.

“What is your turnaround time to be reimbursed?” Most insurance companies will say they can complete claims within 30 business days.

Step 2: Fill out your Claim Form

Step 3: Attach a Copy of Your Invoice from the COPD Store/1st Class Medical

NOTE: Supplies ordered on your invoice will need to be split into additional HCPCS billing codes. Example: Most CPAP masks will include headgear. Insurance companies process the cost of the mask alone and then they will process the cost of the headgear. When you send your invoice make sure you make all the appropriate separations. As a general rule your mask will accrue 70% of the total cost you paid and your headgear will be the additional 30%. By using this formula you should be able to find the correct codes for your insurance company.

Step 4: Submit the claim either by mail or some companies will accept a fax.

Step 5: Sit back and wait to be reimbursed. Most insurance companies will say they can complete claims within 30 business days.

HCPCS Insurance Billing Codes

The following HCPCS codes are used by insurance companies to process claims. Please use the appropriate code on your claim form to ensure timely processing. Codes should correspond to each separate item on your invoice.

Please Note: Items such as CPAP bed pillows, batteries, and DC adapters are not covered as they are considered luxury items.

  • E0601 - CPAP machine purchase
  • A7034 - CPAP nasal mask
  • A7032 - CPAP nasal mask cushion
  • A7030 - CPAP Full Face mask
  • A7031 - CPAP Full Face mask cushion
  • A7044 - CPAP Full Oral Interface
  • A7046 - CPAP Humidifier Chamber
  • A7037 - CPAP tubing, long and short hoses
  • A7038 - CPAP disposable filter
  • A7039 - CPAP foam filter
  • A7035 - CPAP headgear
  • A7033 - CPAP nasal pillows
  • A7036 - CPAP chinstrap
  • E0561 - CPAP Passover Humidifier
  • E0562 - CPAP Heated Humidifier
  • E0470 - BiPAP purchase
  • E0471 - BiPAP-ST purchase
  • A4604 - Thermo Smart Tube
  • K0553 - Oral/Nasal (Hybrid) Mask
  • K0554 - Oral Cushion for Hybrid Mask
  • K0555 - Nasal Cushion for Hybrid Mask
  • E1399 - CPAP Miscellaneous (this code is to be used for any CPAP items covered by your insurance but not listed above.
  • E1392- Portable Oxygen Concentrator
  • E1390- Home Oxygen Concentrator 
  • A7034 is Nasal Mask
  • A7034 is Nasal Pillow Mask
  • A7030 is Full Face Mask
  • A7027 is Hybrid Mask
  • A7044 is Oral Interface Mask (Oracle)
  • A7035 is Headgear for Mask - Any Style
  • A7036 is Chinstrap - Any Style
  • A7032 is Replacement Nasal Mask Cushion
  • A7033 is Replacement Nasal pillows
  • A7031 is Replacement Full Face Mask Cushion
  • A7028 is Replacement Hybrid Mask Cushion
  • A7029 is Replacement Hybrid Mask Nasal Pillow
  • A7046 is Replacement Humidifier Chamber
  • A7037 is Tubing / Hose - Long & Short Tubes
  • A4604 is Heated Tubing
  • A7038 is Disposable Filter (White / Paper)
  • A7039 is Washable Filter (Gross Particle / Foam/ Black)
  • E0601 NU is CPAP Purchase
  • E0601 NU is APAP Purchase
  • E0470 NU is BiPAP Purchase
  • E0470 NU is BiPAP Auto Purchase
  • E0471 NU is BiPAP ST Purchase
  • E0471 NU is BiPAP Auto SV Purchase
  • E0562 NU is Heated CPAP Humidifier
  • E0561 NU is Passover or Cool CPAP Humidifier
  • E0601 RR is CPAP Rental
  • E0601 NU is APAP Rental
  • E0470 RR is BiPAP Rental
  • E0470 RR is BiPAP Auto Rental
  • E0471 RR is BiPAP ST Rental
  • E0471 RR is BiPAP Auto SV Rental

Physician Diagnosis Code

Insurance companies require you provide a code associated with your specific medical diagnosis.

  • Chronic obstructive pulmonary disease (COPD) includes chronic bronchitis (ICD-9 codes 490-491),
  • Obstructive Sleep Apnea is ICD-9 code 327.23,
  • Emphysema (ICD-9 code 492),
  • Bronchiectasis (ICD-9 code 494),
  • Chronic airway obstruction (ICD-9 code 496).
  • Asthma (ICD-9 code 493)
  • Hypersensitivity pneumonitis (ICD-9 code 4950.
  • To ensure that you have the correct code for your diagnosis, contact your physician.

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