Insurance and Billing Information

As a courtesy to our patients, PPS Orthotic & Prosthetic Services makes every effort to file the your insurance claims for you. Under certain circumstances, the patient may be responsible for part or all of the cost of the device. A signed prescription is required from your physician.

Once you have decided for PPS to provide you with our services, we will ask you for some basic information. We are contracted with many insurance companies, third-party administrators, as well as employers. Our products are billed under the DME benefits of coverage and usually follow the same guidelines as your major medical. Please be aware, many insurances require authorization and may take a minimum of two weeks to get the authorization before we can deliver a device. We may give you an estimate of the cost, but final billings will be based on what your insurance carrier pays.

Preauthorization

Insurance companies such as Amerigroup, worker's comp, some Medicare HMO's, as well as some other companies require pre-authorization and most take a minimum of two weeks to get a response. We are now giving patients an option of either waiting for pre-authorization or taking the device as soon as we can have it ready for fitting.

Major Insurance Contracts:

Acordia Alliant
Blue Cross of GA
Blue Cross of TN
Cigna
GA Medicaid
Healthspring
Humana
Medicare
TN Medicaid
Tenncare

Should your insurance company not be listed, please contact our Billing Specialist and we will be happy to discuss your coverage with you and contact your carrier for verification.

Dianne Brown
Business Manager
423-697-0057, ext 129
dianne@oandpa.com

Medicare Part A and B Coverage

CMS (Centers for Medicare and Medicaid) coverage is dictated by law and regulated by the Prospective Payment System. This system was implemented to prevent fraud, abuse, and over-utilization in the provision of primarily DME (Durable Medical Equipment) but also affects the provision of orthotic services for persons that are in-patients in hospitals, rehabilitation centers, nursing homes and other health care facilities. Patients may have either Part A (in-patient, hospital)
coverage, Part B (out-patient coverage) or both.

All prosthetic services (artificial limbs) are exempt from prospective Payment System regulations for individuals covered under Part B and canbe provided to patients in any of the health care settings described above.

PART A: Patients who are in-patients of a healthcare facility and covered under Part A of Medicare are eligible for orthotic and prosthetic services ONLY if the healthcare facility provides a purchase order for the services or if the patient agrees to pay for the services.
PART B: Patients with both Part A and Part B, who are in-patients of an acute healthcare facility (hospital, etc.) but covered under Part A, will also require a purchase order from the healthcare facility in order to receive orthotic services provided. (Prostheses can be provided in this setting, and CMS billed by the provider under Part B, at no cost to the healthcare facility)

Note: For the above patients, orthotic services delivered within 48 hours of discharge, on the discharge date, or after the discharge date are billed by the provider under part B and at no cost to the healthcare facility. The patient is responsible only for the normal co-payment of the Medicare allowable charges under CMS Part B guidelines.

PART B Nursing Home Patients: Patients who enter nursing homes have 100 days of Part A coverage per year. During this time, provision of orthotic services can ONLY be provided if the healthcare facility provides a purchase order. After the 100 days, for patients who qualify as “skilled”, the normal 48 hour window applies and orthotic services are billed by the provider under part B at no cost to the healthcare facility. The patient is responsible for the normal co-payment of the Medicare allowable charges under CMS Part B guidelines. For “resident” Part B patients, no restrictions on services apply. ( Prostheses can be provided at any time, without cost to the healthcare facility.)

All consults require a written order from the physician or therapist and must be placed in the patient’s chart. After evaluation, a detailed, CMS compliant prescription, will be sent to the physician for his/ her signature. Consults can be faxed to our office, along with face sheet to begin the process.

PPS Orthotic and Prosthetic Services will evaluate a patient and make a recommendation to the physician or physical therapist on treatment options at no cost to the patient or to the facility.