Q: What is DME?
A: DME stands for durable medical equipment. There may be times when you require DME/Prosthetics/Orthotics. Some examples are medically necessary, including crutches, wheelchairs and respirators. Those are prescribed by your primary care physician, or perhaps the physician that attended to you in the hospital or rehabilitation facility, and primarily used as equipment following an illness or injury. It is to be used in the home.
Q: Are all DME suppliers participating?
A: No, DME providers just like facilities, professional providers, pharmacies, can be in-network participating providers or out-of-network, nonparticipating providers.
Q: How do I verify if my DME supplier is participating?
A: You should follow three steps to verify if a supplier is a participating in-network provider:
1. Ask the physician prescribing the DME whether they are an in-network DME supplier. Please note that sometimes your physician may not know if that provider accepts or participates with Highmark Blue Cross Blue Shield.
2. Check the Highmark website at HighmarkBCBS.com.
3. To be safe, contact the provider to verify if they are an
in-network participating provider with your Highmark plan.
Q: When can you be in a hospital, stay overnight, and yet not be considered an in-patient in that hospital?
A: Observation room/services are defined as the use of a bed and periodic monitoring by the hospital’s nursing or other ancillary staff, which are medically necessary to evaluate an outpatient’s condition or determine the need for a possible in-patient admission.
Q: What is the typical amount of time
to be under observation services?
A: The standard time is 24 to 48 hours.
Q: Let’s assume I am going to either an Enhanced tier provider—in which case I don’t have a deductible or out-of-pocket expense for covered services at the facility—or I am going to a Standard tier provider and my deductible and out of pocket has already been met. Do I owe anything to that hospital?
A: Yes you do. For observation services, the hospital may charge you the emergency room copay, even if you didn’t come in through the ER. For Allegheny County Schools Health Insurance Consortium members, that copay amount is $100.
