How to Get Reimbursed (Medicare, Medicaid, Atena, Cigna, and more) When You Use Private Pay 

EW-M39 Portable Comfort Electric Scooter by EWheels Medical

According to the National Institute of Health, more than 6 million people in the United States use mobility devices; an estimated two-thirds of this population are adults over 65.

If you’re part of this population or have a loved one with mobility limitations, you know purchasing a wheelchair, ramp, electric scooter, or patient ceiling lift can be a significant financial investment. 

However, if you have wheelchair insurance coverage from Medicare, Medicaid, or private insurance organizations like Cigna or Humana, you can offset associated costs via reimbursement. 

You may think that if you or your loved one are 65 or older and need insurance reimbursement for electric scooters or other mobility devices, Medicare or Medicaid will automatically cover them, this isn't true. 

Whether Medicare, Medicaid, or your private insurance will reimburse you for the cost of a patient lift, power chair, or electric scooter, depends on if you meet their eligibility requirements. 

This article provides a comprehensive guide to navigating the Medicare, Medicaid, and private insurance reimbursement process for mobility devices. We will explain the essential steps involved for each option, from understanding eligibility requirements to gathering the necessary documentation and submitting your claim. 

By adhering to these guidelines you can increase the chances of getting reimbursement for your purchase. 

Will Medicare Cover a Scooter? Understanding DME Insurance Coverage Eligibility Requirements and Reimbursement Process 

Regal Power Rear-Wheel-Drive Wheelchair P310 by Merits

In the last few years, the Centers for Medicare and Medicaid Services (CMS) modified its requirements for covering mobility devices under the Medicare Part B program. 

These changes were due to an increase in fraud cases concerning electric scooter and power wheelchair claims, referred to by CMS as Power Mobility Devices (PMDs). 

Listed below are the requirements to be eligible for Durable Medical Equipment (DME) reimbursement coverage of Medicare benefits. Understanding and adhering to the requirements is the most important step in the reimbursement process. 

Power Mobility Device Must be Used Primarily At Home

Beneficiaries who want coverage for a mobility device like a power wheelchair or patient lift, must have a temporary or permanent disability that impairs mobility. 

Under Medicare Part B, the rental or cost of purchase for a mobility device will be covered as long as the Durable Medical Equipment (DME) is used primarily at home or in a facility used as a residential space. 

So Medicare covers electric wheelchairs, scooters, or lifts if you intend to use them in your home. Medicare does not consider a hospital or nursing facility a home. So if you’re a beneficiary in such a facility you will not be eligible for reimbursement for DMEs whether powered or manual. 

A common misconception among Medicare Part B beneficiaries is mixing up the term “in the home", with the belief that it means that their wheelchair, or motorized patient lift cannot be used outside their house. 

On the contrary, the term relates to whether the need for a mobility device is based on improving patient mobility for activities within the home. The Afikim eFOLDi Explorer Folding Scooter is a good example, of a necessary mobility device built for dual use (indoor and outdoor). 

Also, whether the beneficiary lives with or without family does not impact eligibility with Medicare. 

As a beneficiary, you need to show the willingness and capacity to use the mobility device safely at home and that the DME will improve mobility and health. 

Medicare considers the improvement of health through the mobility device as when the DME to be reimbursed can be used to assist the patient in performing personal care tasks where the inability to execute them would harm the beneficiary's health. 

Personal care tasks include bathing, grooming, feeding, and other Mobility Related Activities of Daily Living (MRADL). 

Assessment Tool Test for Mobility Device Eligibility 

The Centers for Medicare and Medicaid Services (CMS), uses an assessment tool that helps the insurance body determine if a Mobility Assistive Equipment is appropriate (eligible for reimbursement) for a particular beneficiary. 

The assessment is crafted to determine if the chosen mobility device will improve the health of the beneficiary by allowing them to perform MRADL on their own. The assessment is only done on the patient willing to use the mobility device. 

That said, the assessment tool contains 9 questions and a flow chart to help the medical practitioner determine the right DME for the beneficiary. This assessment tool is an improved version of the previous one which was known as the “bed or chair confined” standard. 

So the caregiver, beneficiary, and their doctor must meet face-to-face to choose the right mobility device. 

The following are the 9 assessment questions focused on the beneficiary. Their answers, when possible, must be supported by documentation. 

STEP 1

Does the Beneficiary (Patient) have a Mobility Limitation that Significantly Impairs Their Ability to Participate in One or More MRADLs at Home?

This includes being able to perform tasks and the risk of injury when attempting the MRADL. Also, the time taken for the beneficiary to perform a MRADL can affect the determination of the patient’s limitation.

STEP 2

Are there Other Conditions that Affect the Beneficiary's Ability to Participate in MRADLs at Home? Does the Beneficiary Have Other Conditions that Limit their Ability to Participate in MRADLs at Home? 

This assessment determines if the patient has other conditions beyond mobility challenges such as cognition or vision problems which can not be aided by a mobility device but can limit their ability to use the wheelchair, patient lift, or electric scooter safely. 

If such limitations exist, can they be compensated or made tolerable sufficiently such as that the use of a mobility device will be expected to improve the patient’s ability to perform or get help to participate in MRADLs at home? Note that this is inclusive of caregiver assistance in the use of DME. 

For instance, a Bariatric patient lift would provide additional compensation for limited mobility persons with higher weight capacities when a regular DME won’t. 

Molift Partner 255 Electric Powered Mobile Patient Lift by ETAC

Also, if there is a way to reduce the impact of these other limitations beyond mobility, that require the patient to undergo treatment, coverage could be denied if the condition doesn't get better to allow them to use the mobility device safely. 

Reimbursement can also be denied if the help the caregiver provides does not reduce the impact of the condition. 

STEP 3

If Other Conditions Exist, Can they Be Compensated or Ameliorated Significantly Such that the Additional Provision of a Mobility Device will be Expected to Improve the Beneficiary’s Ability to Perform or Receive Assistance to Participate in MRADLs at Home?

This includes caregiver assistance in using the mobility device. Also, if there is a way to minimize the limitations mentioned in question 2 above that require the patient to undergo treatment, coverage could be denied if the condition doesn’t improve enough to allow the beneficiary to use the mobility device safely. Coverage can also be denied if the help offered by the caregiver does not minimize the condition. 

STEP 4

Does the Caregiver or Beneficiary Demonstrate the Capability/Willingness to Operate the Mobility Device Safely?

This isn't just the determination of the patient's safety when using the mobility device (power wheelchair, patient lifts, etc), but also that of the people around them. 

Medicare will consider any history of unsafe behavior as well. This is assessed by having the patient use a variety of other devices that can help boost their independence. 

STEP 5

Can the Functional Mobility Deficit be Significantly Resolved by the Prescription of a Cane or Walker? 

These criteria will aid the medical practitioner in assessing the Medicare Part B beneficiary for the best mobility device, both from the standpoint of safety considerations and improving overall health. 

STEP 6

Does the Patient's Typical Environment Allow the Use of Wheelchairs including Power Wheelchairs? 

The beneficiary's living environment will be assessed including surfaces, physical layout, and obstacles that could make using a powered wheelchair or electric scooter harder. Changes to the beneficiary's home like the installation of accessibility ramps, may be necessary if needed. 

TRANSITIONS Modular Entry Ramps by EZ-ACCESS

STEP 7

Does the Beneficiary have Adequate Upper Extremity Function to Move a Manual Wheelchair at Home or Participate in MRADLs Daily?  

If a manual wheelchair is to be purchased it must be configured to suit the beneficiary. This includes wheelbase, seating options, device weight, and other appropriate accessories. 

The assessment will cover the beneficiary's upper body strength, range of motion, and endurance. 

Also, the availability of a caregiver who can help move the manual wheelchair will also be considered. Plus, the ability to use the wheelchair safely at home is considered. 

STEP 8

Does the Beneficiary Have Sufficient Postural Stability and Strength to Move a Power Wheelchair or Scooter? 

Patients/Medicare Beneficiaries must demonstrate that they can maintain stability to properly operate a powered mobility device. A device with joystick operation like the 6Runner 14 Power Wheelchair by Shoprider will demand lower upper body strength. 

STEP 9

Does the Power Wheelchair Have Additional Features Needed to Allow the Beneficiary to Participate in Other MRADLs? 

The main features of a power mobility device that can make it more appealing are its accommodation of a variety of seating needs and ease of transfers. These features of a mobility device like a patient lift with a remote control, are a crucial part of determining if it is going to improve the beneficiary's mobility. 

P-440 Portable Ceiling Patient Lift by Handicare with Remote Control

Prescription Requirement and Face-to-Face Examination

The Medicare-approved medical practitioner treating the beneficiary must conduct a face-to-face examination before writing a mobility device prescription. 

The practitioner must then write, sign, and date a prescription that must be received by a Medicare-approved DME supplier within 45 days of the examination. 

If the Medicare beneficiary was recently discharged from the hospital and the practitioner has already done a face-to-face examination of the beneficiary during their stay, there is no need for another one. This is as long as the prescription and documentation received by the DME supplier are within 45 days of the discharge date. 

Also, the prescribing physician must provide additional documentation, which includes medical records or other documents that help in revealing the history of the patient's need for the mobility device. 

The documentation must also show that the wheelchair, scooter, or patient lift will improve the beneficiary's mobility and that they can use it safely. 

CMS permits payment for the cost of the face-to-face examination and the collection cost of additional documentation. All required documentation must be given to the supplier before they submit the claim to the CMS. Suppliers will need to maintain the documentation for 7 years. 

Advanced Determination of Medical Coverage (ADMC) 

Medical and beneficiaries may need to get an Advanced Determination of Medical Coverage (ADMC) from the DMC regional carrier. 

Getting the ADMC doesn't require the same level of documentation needed for Medicare coverage determination. 

However, it can help the patient to assess potential issues that can impede coverage. Note though that a positive ADMC does not imply Medicare coverage is guaranteed. The full assessment and supporting documentation may reveal a reason for the reimbursement request denial. 

Payment Responsibility

Before a purchase, beneficiaries must ensure that the DME supplier they are working with is an approved Medicare supplier with an identification number from the insurance body. 

Beneficiaries are expected to pay 20% of the amount authorized by Medicare. 

However, if the supplier does not participate in Medicare's physician/supplier assignment program (that is the supplier does not agree to accept Medicare's reasonable charge calculation as payment in full with the beneficiary paying the 20% responsibility) then the beneficiary will be charged the difference of Medicare's reasonable charge calculation and the price of the mobility device from the supplier. 

So Medicare beneficiaries would want to work with a participating supplier to reduce the out-of-pocket costs. 

Medicare Coverage Eligibility Recap

Beneficiaries considering “Will Medicare cover wheelchairs?” Or does “Medicare pay for scooters?”, the answer is yes.

This is provided that they can prove mobility limitations that impede their ability to engage in MRADLs and that their use of a mobility device will enhance their ability to perform daily tasks. 

EW-M39 Portable Comfort Electric Scooter by EWheels Medical

Beneficiaries must also prove that the mobility device can be used safely at home. 

Also, Medicare beneficiaries must ensure that their practitioner provides the Medicare supplier with all needed documentation including the prescription for the mobility device within 45 days of the in-person examination. 

First Way to Get Medicare Reimbursement After Paying Out-the-pocket

Step 1

Ask customer care if your Medicare coverage requires “Prior Authorization” before paying for a mobility device. Generally, if you are covered by Medicare Part A or Part B, you rarely need prior authorization as many services needed are pre-approved. Most wheelchairs and patient lifts have medical billing codes under Medicare, which you can check to confirm. 

Step 2 

Visit your Medicare-approved doctor to get a prescription for the mobility device.  

Step 3

Find out if you've satisfied your annual deductible so you'll know what to pay for the mobility device. In 2024, the annual deductible is $240.

Step 4 

Ask the DME supplier to submit a prior authorization request if required. If it is denied, then you need to work with the DME supplier and medical practitioner to provide the additional documentation Medicare needs.

Step 5

If it is pre-approved you can proceed to pay for the product on Wheelchair Liberty and then submit a reimbursement claim to Medicare using your purchase receipt. 

Second Way to Get Medicare Reimbursement for Mobility Device After Paying Out-the-pocket

This method is a lot easier and requires the patient or beneficiary to find a provider such as a DME Local store or doctor's office who accepts the assignment and acts as an intermediary. 

The intermediary does the paperwork involved and requests reimbursement from Medicare. In this scenario, your local DME supplier or doctor's office will purchase the mobility device directly from Wheelchair Liberty. 

Note that this is after you meet the Part B deductible which in 2024 is $240. You must also pay 20% of the Medicare-approved amount for the particular mobility device. 

In both ways, you must ensure that your doctor is enrolled in Medicare. Also, ensure that your DME supplier participates in Medicare. 

Medicaid - Eligibility Requirements and Reimbursement Process 

Medicaid is the largest insurance program providing health and medical services to low-income individuals. 

It is 100% state-managed and pays for pre-approved or covered medical services. 

This means that the eligibility criteria for Medicaid reimbursement after out-of-pocket purchases, unlike Medicare, vary per state. 

For Medicaid: 

• Each state places its eligibility standards 
• Each state sets the amount, type, duration, and scope of services it covers 
• Every state is the administrator of its Medicaid program 
• Medical Assistive Equipment like power wheelchairs or scooters are covered as Durable Medical Equipment under Medicaid 

So yes Medicaid covers wheelchairs and scooters for reimbursement. 

However, this is for patients who meet the full Medicaid eligibility criteria and pass the medical necessity assessment. 

Again, Medicaid eligibility requirements differ from state to state. 

For example, with Medicaid Alabama, all requests for wheelchairs are subject to prior approval and the program authorizes DME to Medicaid recipients of any age living at home. 

Some general eligibility requirements for Medicaid include: 

• The DME purchased or to be purchased must be for medical therapeutic reasons 
• The mobility device to be purchased must minimize the necessity for a nursing facility, hospitalization, or similar institutional care. 

Beyond these, to qualify for Medicaid, state residents must satisfy low-income and resource limits. 

They must also be medically needy and fall into the eligibility category specified by the state. 

Individuals receiving Supplementary Security Income (SSI) benefits are generally automatically eligible for Medicaid. 

Medicaid will only reimburse or pay for a motorized wheelchair if the patient has a medical need for the particular power wheelchair. 

The state insurance program will also request a doctor's prescription written for the patient and the particular power wheelchair or electric scooter. 

Motorized wheelchairs are covered under Durable Medical Equipment under Medicaid, but the circumstances of coverage differ from state to state. 

Some state variations include: 

• Coverage for accessories or add-ons
• Age limitation coverage for some states
• Coverage for skilled nursing homes 
• Coverage for vocational and outdoor use
• Whether patients can purchase or rent particular power chairs 
• Certain states require patients to undergo physical therapy and submit reports as well as complete specialized forms 
• For beneficiaries that qualify for both Medicaid and Medicare, Medicaid will sometimes reimburse the portion of the cost of a DME that isn’t covered by Medicare (the 20%).

Additionally, Medicaid in certain states may also cover the cost of a power-adjustable seat height on an electric wheelchair. 

Jimmie Portable Power Wheelchair with Adjustable Seat by Shoprider 

However, this is usually on a case-by-case basis where it is proven to be essential for reaching, transfers, safety, access, communication, and/or to support mentioned educational or vocational goals. 

That said, Medicaid, regardless of the state, requires that a medical practitioner (termed a prescriber), must be licensed and active with the state’s Medicaid program. 

They must also prescribe a wheelchair or scooter that aligns with their plan of treatment. 

In addition, most states require Prior Authorization requests for the coverage of DME to be sent in by Medicaid’s Fiscal Agent within 30 days after the equipment is dispensed. 

Most states also have documents stating their reimbursement rates and benefit limits on covered DME.

Medicaid General Guidelines for Reimbursement of Durable Medical Equipment (DME) Out-of-pocket Payments

Listed below are the general steps to obtain Medicaid reimbursement for your private pay purchase of an approved DME/mobility device from Wheelchair Liberty. 

Remember, that beyond these steps each state may have additional requirements to be eligible for reimbursement. 

Step 1 

Get a valid prescription from a Medicaid-licensed medical practitioner in your state for DME. 

This should be alongside a face-to-face examination report if the particular state requires one for eligibility.

Step 2

Verify that the DME you intend to purchase is covered by your state’s Medicaid program. 

You can check this by going to the program’s website or by contacting Medicaid directly. 

Step 3

You need to gather relevant documentation including a valid prescription from your Medicaid-approved healthcare provider, and a copy of your purchase receipt. 

The receipt must show the date, cost, and description of the purchased item. 

You also need supporting medical documentation that justifies the need for the purchased DME. This can be provided by your doctor.

Step 4

Next, you need to submit a claim for the purchase by filling out the reimbursement claim form. 

The form is generally available on your state’s Medicaid website. If you can’t find it, contact the program’s customer service.

Step 5

At this point, wait for Medicaid to review/process your reimbursement claim and determine your eligibility based on the provided documentation. 

The process can take a couple of weeks. If your claim is approved then you’ll receive your reimbursement. 

However, if it isn’t, your state’s Medicaid program will send you a letter explaining the reason for denial, outlining your appeal options. 

Specific Rules 

Keep in mind that some states require provider enrollment. This means that the provider from whom you purchased the mobility device must be enrolled with Medicaid. 

In such cases, you can buy a DME through an enrolled intermediary supplier that will purchase the mobility device directly from Wheelchair Liberty and submit paperwork on your behalf for reimbursement claims. 

Also, some state programs require prior authorization for certain DME like power wheelchairs before purchase. 

Atlantis Heavy-Duty Power Wheelchair P710 By Merits

There may also be a preferred network of suppliers and buying DME from providers outside the network may impact reimbursement success. 

So ensure you check the particular requirements of your state’s Medicaid program. 

Private Insurance

Blue Cross Blue Shield Eligibility and How to Receive Out-of-pocket Payment Reimbursement

Blue Cross Blue Shield (BSBC) covers manual wheelchairs and power wheelchairs which it classifies as Durable Medical Equipment (DME). However, as in the case of Medicaid, the requirements of coverage differ based on the state. But it has core requirements irrespective of state. 

Manual and motorized wheelchairs are considered eligible for coverage (in this case reimbursement not payment) on an individual basis. BSBC will also provide coverage for wheelchairs when they are determined medically necessary for the beneficiary. 

This means the medical criteria and guidelines laid out by Blue Cross Blue Shield must be met before reimbursement. 

Also, Blue Shield Blue Cross covers adjustment, repairs, accessories, or components on an individual basis. For adjustment, repairs, or accessory purchases, the beneficiary must document reasonable care of the DME.

 

Lithium Battery (Transformer 2 & Mobie Plus) Accessories By Enhance Mobility

Blue Shield Blue Cross does not cover DME used for environmental accommodation, such as ramps, chair lifts, stair lifts, standing frames, and home elevators, which are all excluded from most health benefit plans. 

Blue Shield Blue Cross also does not reimburse or fulfill claims on DMEs that serve no medical purpose or that are considered a convenience. 

The DMEs purchased must be medically necessary in the sense that they do not primarily serve a therapeutic purpose though they may aid in the patient's independence or assist caretakers 

Blue Shield Blue Cross considers power-operated vehicles (electric scooters) to be built for convenience and excludes them from coverage. So “will Blue Shield Blue Cross cover electric scooters?” Unfortunately, no. 

Also, before purchase/reimbursement individual certificates or member benefits must be reviewed to verify eligibility and any prior approval or pre-authorization needed for the purchase of the DME. 

The reimbursement of out-of-pocket expenses will be made based on the severity of illness, prognosis, and review of diagnosis. Also, the DME supplier must satisfy eligibility and credentialing requirements as defined by the state’s BSBC to be eligible for reimbursement. 

So if you decide to use a local DME as an intermediary then they must be eligible per the program's requirement. Again, BSBC does not cover accessory items such as access ramps, car lifts, or any other type of lift. 

That said, Blue Shield Blue Cross, covers wheelchairs when they are considered medically necessary for the performance of activities of daily living in the beneficiary’s residence and when the below criteria are satisfied:

• The determination of purchase reimbursement is made based on a review of the beneficiary's diagnosis, prognosis, and severity of illness. This means that there must be a face-to-face examination of the patient to document a medical report before purchase.
• The wheelchair purchased must be appropriate for the beneficiary's weight 
• The wheelchair must be prescribed by a doctor within the scope of his/her license
• Medically needed adjustments or add-on accessories are based on a review of documented reasonable care of the equipment. 

For manually operated wheelchairs, the insurance program considers it necessary under the following conditions:

• The beneficiary has an injury or disability or a disease process that contraindicates weight bearing or ambulation
• The patient has a disease process, disability, or injury that causes a decreasing neuromuscular function in their lower extremities
• The beneficiary can self-propel their wheelchair.

For power wheelchairs, a medical practitioner must determine that a manually operated wheelchair is inadequate to address the beneficiary's need for mobility in their home. This must be because the insurance member does not have adequate upper extremity function to self-propel a properly configured manual wheelchair at home to carry out Mobility-related 

Activities of Daily Living (MRADLs) daily. 

Other requirements include: 

• The beneficiary can safely operate the control of a powered wheelchair 
• The BSBC member has a condition involving a disease process, disability, or injury that contradicts weight bearing or ambulation, or results in reduced neuromuscular function in all four extremities. 
• A member must also require support of the trunk or possess other neurological conditions that seriously compromise functional status such as but not limited to stroke with dense hemiplegia,  Parkinson's disease, ALS, and spinal cord injury

How to Receive Reimbursement from Blue Cross Blue Shield After Paying Out of pocket for a DME from Wheelchair Liberty

Step 1 

Set up a doctor's appointment for a face-to-face examination to confirm that your mobility condition is eligible for a wheelchair.

If this has already been done recently and there are documents from the doctor's office proving it then you just need to get a prescription from the doctor's office for the particular type of wheelchair you intend to purchase. 

Step 2 

Confirm that the wheelchair prescribed by the doctor is covered by your state's Blue Shield Blue Cross program. 

Step 3

Go to Wheelchair Liberty and pay for the prescribed DME. 

Step 4

Next, go to your state's Blue Cross Blue Shield website and fill out the reimbursement form/claim form. You will be required to attach your doctor's prescription, doctor's report, and invoice for the payment. 

Step 5 

Wait for Blue Shield Blue Cross to review your submissions and if successful you'll receive your reimbursement. If not BSBC will inform you why it was rejected. 

Alternate Step 

The other option is that you go to an approved BSBC DME supplier to act as an intermediary for you. With this approach, the supplier will simply receive your documentation (doctor's prescription, condition records, etc) and then buy the DME from Wheelchair Liberty. They will then proceed to file the claim for reimbursement for you. In this case, you won't have to do anything. 

Aetna Eligibility and How to Receive Out-of-pocket Payment Reimbursement

Aetna considers wheelchairs and power-operated vehicles to be durable medical equipment and eligible for coverage to members enrolled in insurance plans that provide this benefit. 

This includes power wheelchairs, electric scooters, seating components, power assist devices, power features, positioning components, and power/ manual wheelchair accessories. 

Transformer 2 Folding Electric Scooter by Enhance Mobility

That said, there are several eligibility requirements Aetna considers for insurance on wheelchairs and other power-operated vehicles. Let's examine some of these eligibility requirements 

Medical Necessity 

Aetna considers wheelchairs and other accessories or attachments medically necessary if the individual is unable to ambulate about the home without the use of a wheelchair and other medically necessary attachments or accessories. 

The eligibility requirements vary based on the type of wheelchair (manual, electric or power wheelchairs and power mobility devices). 

Wheelchairs for use within the home are considered necessary if they meet the following criteria: 

• The member must have a mobility limitation that hinders their ability to participate in mobility-related activities for daily living. The mobility limitation prevents the individual from accomplishing an MRADL, completing an MRADL within a reasonable timeframe or puts the individual at a determined high risk of morbidity or mortality during attempts to perform MRADL. 
• The mobility limitation experienced by the user cannot be resolved with the use of an appropriately fitted walker or cane. 
• It should also be clear that the use of the wheelchair will significantly improve the user’s mobility limitations and the individual uses it regularly in the home. 
• The individual's home must be properly fitted and provide adequate access between rooms and surfaces to ensure adequate use of the wheelchair. The presence of wheelchair ramps, for example.
• For manual wheelchairs, the individual used must also have sufficient upper extremity function as well as the physical and mental capacity to safely propel the manual wheelchair. 
• For Electric, Power, or Motorized Wheelchairs, the user should not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair in the home to perform MRADLs. 
• The individual is also required to have an available caregiver who is willing to provide the needed assistance with the wheelchair. 

Aetna does not consider manual wheelchairs that do not meet the above criteria medically necessary. Also, manual wheelchairs designated for use outside the home are not considered medically necessary. 

Pioneer 10 4-Wheeled Outdoor Electric Scooter S341 by Merits

For electric or power wheelchairs, the user must have the required mental and physical capacity to operate the wheelchair or must have a caregiver who is available to assist them use the wheelchair. 

For power wheelchairs, the user's weight should be less than or equal to the weight capacity of the wheelchair, and the user’s weight must also be more than or equal to 95% of the weight capacity of the next lower-weight class PWC.

Wheelchair attachments, accessories, or upgrades that are used to adapt to the outside environment for work or leisure activities are considered convenience items and, hence not medically necessary. 

Documentation Requirements 

A Standard Written Order (SWO) 

Aetna requires a Standard Written Order, before claim submissions of all accessories supplies and options billed in addition to the wheelchair base at any time. 

The SWO can be prepared by anyone other than a treating practitioner, but the SWO must be signed and reviewed by a treating practitioner. 

Also, in line with CMS policy, the item must be correctly coded by meeting all coding guidelines, it must also be listed in the Pricing, Data Analysis and Coding (PDAC) Product Classification List. 

Claims that do not meet coding guidelines or are incorrectly coded are considered medically unnecessary and will be denied. 

Face-to-Face Examination 

Aetna requires that the treating physician conduct a face-to-face examination with the individual within 6 months of signing the SWO. The examination aims to provide information relating to the following:

• The individual's mobility limitations and how the limitations interfere with their performance of MRADL 
• Why a walker or cane cannot meet the individual's mobility needs in the home 
• In the case of an electric wheelchair, the physician needs to state why a manual wheelchair cannot meet the individual's mobility needs at home
• If a power wheelchair is required, the physician must state why a POV (scooter) cannot meet the individual's mobility needs in the home. 
• Face to face examination is also required to ensure that the individual has the physical or cognitive abilities to safely operate the wheelchair at home. If this is lacking, they must have a caregiver available to help them. 

Specialty Evaluation 

This is also a part of the face-to-face evaluation for individuals who receive an ultra lightweight manual wheelchair Tilt-in Space MWC Group 2 Single power or Multiple Power Options Power Wheelchair (PWC), any Group 3 PWC, and power add-on devices. 

The specialty evaluation can be performed by a licensed or certified medical professional that has specific training and experience in rehabilitation wheelchair evaluations. 

The speciality evaluation is tailored to the individual's condition including mobility limitations, home environment, caregivers, postural asymmetries, ability to perform MRADLs, etc. 

The speciality evaluation must also provide detailed explanation on why each specific accessory or option is medically necessary to address the individual's mobility limitations. 

Aetna does not consider supplier-produced records and attestation letters to be a part of a medical record. Certificates of Medical Necessity must be corroborated with information in the medical record. 

Supplier and Assistive Technology Professional (ATP) Eligibility and Responsibility

One of Aetna’s requirements is that an ultra lightweight MWC, Tilt-in Space MWC Group 2 Single power or Multiple Power Options PWC, and any Group 3 PWC must be provided by a supplier that employs a RESNA-certified Assistive Technology Professional. 

EZ-GO Deluxe Portable Power Wheelchair by Merits

The Assistive Technology Professional (ATP) must specialize in wheelchairs and have direct involvement in the selection of a wheelchair for the user. 

The ATP must perform a home assessment and provide written documentation stating that the home is accessible for the exact wheelchair requested. 

How To File A Claim With Aetna 

Aetna requires members to file claims within 180 days from the date the service was provided (after purchasing from Wheelchair Liberty out-of-pocket). Aetna supports the filing of claims through the Availity Portal and via mail. 

How To Submit Claims Through Availity 

Availity is Aetna’s provider portal that offers a variety of functions including the submission of claims management or patients and authorizations. 

Through the Availity Portal members can easily submit claims, upload medical records and supporting information, check patient benefits and eligibility, file disputes and appeals, and get authorizations and referrals.

To submit claims via Availity, do the following:

• Login into Availity and select the state in the menu bar. 
• Scroll to “Claims & Payments” and select “Claims”
• Select the option labelled “Medicaid Claim Submission – Office Ally.” You will be redirected to the Office Ally website. 
• To submit your claim, use the online claim entry feature or upload a claim file. The status of claims submitted online is managed through the Office Ally Account. 

Aside from Availity Aetna supports the filing of claims through other vendors via Aetna Provider Portal on Availity . Fees may apply depending on the vendor chosen. 

Most of the supported vendors on Aetna’s Provider Portal on Availity offers services such as Electronic Remittance Advice, Claim Status Inquiry, Precertification, Eligibility, Patient Cost Estimator, Electronic Disputes & Appeals, etc. 

Available vendors on Aetna’s Provider Portal include Athena Health, Cerner, Availity, Waystar (formerly NaviCure and ZirMed), Veradigm (formerly Allscripts (PayerPath/Misys), SSI (ClaimsNet), PNT Data, Optum (formerly Change Healthcare), Office Ally, NextGen Healthcare, MediStreams, Jopari, InstaMed, Inovalon (formerly ABILITY Network, Infinedi, Experian Health (formerly Passport Health), and Availity RCM (RealMed). 

Claims Submission Via Mail

Members can submit Aetna reimbursement claims via mail. All that needs to be done is to mail hard copies of the claims to the address below:

• Aetna Better Health® of New Jersey
• Claims and Resubmissions
• PO Box 982967
• El Paso, TX 79998

This is, however, the least preferred method due to its clunky nature. The electronic method is faster and less prone to errors. 

Both fresh claims and resubmissions can be done through mail. But you need to clearly label resubmitted claims with “Resubmission “to avoid the denial of the claims as a duplicate.

Cigna Eligibility and How to Receive Private Pay Reimbursement

In line with the 2005 national coverage decision for mobility assistive equipment by the Centres for Medicare and Medicaid Services (CMS), Cigna ensures that manual/power wheelchairs and scooters are medically necessary for individuals with personal mobility deficit that is capable of impairing their participation in mobility-related activities within the home. 

Cigna offers insurance and reimbursement for the purchase/maintenance of wheelchairs and wheelchair accessories. 

There are, however, several eligibility requirements and considerations for the supported wheelchairs and mobility devices. 

Eligibility Considerations 

Cigna considers wheelchairs and mobility assistive equipment medically necessary under the following conditions:

Medical or Health Problems 

Wheelchairs are considered medically necessary if the user has one or more of the following:

• If the individual is confined to a bed or chair and unable to ambulate around the house without mobility assistive equipment. 
• The individual has a neuromuscular disease or any disease or injury that prevents the use of the lower extremities or contraindicates weight bearing and/or ambulation. 
• The individual has a mobility limitation that prevents them from participating in one or more MRADLs in the home and/or Places them at a reasonably determined heightened risk of morbidity or mortality secondary to the attempts to participate in mobility-related activities for daily living. 

Relevance of The Mobility Assistive Equipment (MAE) 

Once it has been established that mobility limitations exist, the next factor considered is the relevance of the mobility assistive equipment to the individual.

This is to determine if the mobility limitations can be sufficiently compensated or ameliorated by the provision of  MAE and if it will improve the individual's ability to participate in MRADLs in the home. 

Another factor considered is whether the mobility limitation can be resolved by the prescription of a cane or walker. If the individual can safely use a cane or walker, a wheelchair is not considered a medical necessity. 

Also, factors such as limitations of strength, endurance, range of motion, coordination, and absence or deformity in one or both upper extremities are considered to determine the appropriate MAE for the individual. 

For instance, an individual with sufficient upper extremity function may qualify for a manual wheelchair while an individual without upper extremity function may qualify for an electric scooter like the Travel Ease 26 Heavy-Duty Folding Power Wheelchair P183 by Merits.

Travel Ease 26 Heavy-Duty Folding Power Wheelchair P183 by Merits

Willingness To Safely Operate the MAE 

The individual or caregiver's ability or willingness to safely operate the MAE consistently is also considered. 

The MAE must suit the individual's mobility needs and the individual must show willingness to use the MAE for daily activities within the home. 

Safety considerations such as personal risk to the individual as well as others is also considered. If the Individual has a history of unsafe behavior in other venues, it may also be considered. 

Home Environment Considerations 

The individual’s home environment must support the use of wheelchairs and power-operated vehicles. This is to ensure that the MAE will be used as required within the home. 

Factors such as physical layout and surfaces in the house as well the presence of obstacles can make the MAE unusable in the individual's home. 

The home should have appropriate maneuvering space and surfaces for the easy operation of the MAE like the presence of aluminum threshold ramps, for example. 

TRANSITIONS Angled Entry Ramps by EZ-ACCESS

How To Submit A Reimbursement Claim 

Cigna offers reimbursement for medical and dental expenses that qualify as federal income tax deductions regardless of whether or not they exceed the IRS minimum applied to these deductions. 

Wheelchairs and wheelchair accessories are expenses eligible for reimbursement. 

Cigna offers reimbursement claims via the private member area and via ordinary mail. 

How To Submit A Reimbursement Claim Via Your Private Member Area 

Submitting a reimbursement claim via your private member area is quite straightforward. The process is 100% online and the progress status of the claim can be tracked in real-time. 

To submit your reimbursement claim via this method, login to your private member area. Next click “submit a reimbursement claim “follow the onscreen prompts to complete the process. You will also see a list of the required documents you need to attach for the reimbursement claim to be processed. 

If the submitted information is in order, Cigna will reimburse you within 7 working days. 

How To Submit A Reimbursement Claim Via Ordinary Mail 

To claim reimbursement via the ordinary mail method, you need to complete the Cigna reimbursement claim form and include all the necessary documentation. 

Required documents include the original invoice with a breakdown of the cost if the invoice includes several services. 

You also need to include the discharge report, if the Individual with the mobility limitations underwent surgical procedures or hospital admission. A medical prescription for rehabilitation treatment is also required. 

You can also attach the pharmacy ticket in case you made non-hospital pharmaceutical expenses. The claim form and all required documentation can be sent to any of the addresses provided on the Cigna website. 

Reimbursement claims submitted via ordinary mail are paid within 10 days if all required documentation is in order. 

In line with IRS requirements, Cigna requires the receipt for each purchase, this enables it to verify that the expense is eligible for reimbursement. 

The receipt or explanation of benefit for each product must include the following information: 

• Date of Service: This is the date you purchased the product or received the service. If this happened over a few days, enter the start date. 
• Type or Service or Purchase: This includes a detailed explanation of the product you paid for. 
• Amount: The dollar amount paid for the product 
• Name of Health care professional, facility, or store where you bought the MAE. 

Cigna accepts both originals and photocopies of receipts and Explanation of Benefits. 

Humana reimbursement through private pay

Humana is a Medicare Advantage (HMO, PPO, and PFFS) organization and a stand-alone PDP prescription drug plan with a Medicare contract. It is also a Coordinated Care plan with a Medicare contract and a contract with the state Medicaid program. 

Humana covers all medically necessary Durable Medical Equipment supply services. It supports 3 main types of wheelchairs: manual wheelchairs, electric scooters, and power wheelchairs. 

A manual wheelchair is considered necessary if the individual is unable to safely use a walker or cane but has enough upper body strength to propel a manual wheelchair. 

Individuals who do not have the strength to use a cane, walker, or operate a manual wheelchair may qualify for a power-operated scooter if they can sit up and safely operate the scooter. 

Individuals who cannot use a manual wheelchair and do not qualify for a power-operated scooter can get a power wheelchair if they qualify. 

Humana doesn't just cover the purchase of wheelchairs, it also covers the rental of DME items and necessary maintenance of equipment and supplies. 

It also covers services that have a $0 rate on the DME fee schedule, as well as, services not on the DME fee schedule when medically necessary. 

Eligibility Requirements for Humana reimbursement

There are several eligibility requirements Humana considers to determine if a wheelchair or MAE is medically necessary and eligible for Medicare coverage. Eligibility requirements include the following: 

• The individual has limited mobility caused by a health condition that causes significant difficulty moving around the house and performing MRADLs. 
• The individual is unable to perform daily activities even with the help of a crutch, cane, or walker. 
• The  Individual must be able to safely operate and get in and off the MAE. If they are unable to, they must have a caregiver who is available to help them operate the MAE safely. 
• The doctor or supplier must visit the home where the MAE will be used to verify that the MAE can be used safely within the home. The home must not have obstacles or surfaces that can hinder the use of the wheelchair or scooter within the house. 

That said, the doctor treating the individual with mobility limitations must submit a written order known as a Certificate of Necessity to Medicare stating that the individual has a medical need for a wheelchair or scooter for use within the home. 

Also, the supplier and the doctor treating the mobility problems must both accept Medicare. This means you’ll have to go through a Doctor’s office or DME local store that accepts the assignment of purchasing the DME from Wheelchair Liberty and requesting reimbursement on your behalf. 

Humana does not cover DMEs designed for use outside the home as they are not considered medically necessary. It also does not cover accessories or equipment for convenience and comfort like recreational/outdoor scooters.

Mojo Folding Mobility Scooter by Enhance Mobility

Modifications to the home are also not covered. This includes modifications such as ramps, stairs elevators, grab bars, toilet seats, motorized scooters, and disposable or single-use items. 

Humana Claims Submissions 

There are 2 ways to submit claims for reimbursement: electronic claim submission and paper claim submission. 

Electronic Claim Submission 

Reimbursement claims can be made electronically via the Availity Portal and electronic data interchange (EDI) at no cost. 

Individuals who wish to submit their claims through Availity need to register for the Availity Portal on the website. 

Individuals who wish to submit a claim to a clearinghouse can do so using the following payer IDs for Humana:

• Claims: 61101 
• Encounters: 61102 

That said, all Electronic Data Interchange submissions to pass through Availity are done through a process known as Advanced Claims Editing (ACE). Through the ACE process, coding rules are applied to a medical claim submitted through the Availity gateway via EDI before the claim gets to Humana’s claim payment system. 

The aim of this is to ensure that any potential coding issue is quickly identified by a claim submitter; this reduces processing delays caused by incomplete or inaccurate claim data. 

Humana has varying timeframes for the submission of claims.

Medicare Advantage claims must be submitted within one year from the date of the service or as stated in the provider agreement. 

Commercial claims must be submitted within 90 days from the date of the service or no other contractual definition applies. Humana requires valid National Provider Identifiers (NPIs) for electronic claims. 

Paper Claim Submission 

This is the least preferred method of filing claims. To improve cash flow and reduce administrative costs, Humana discourages clinicians and facilities from using paper claim submissions. 

That said, if the need arises, users can submit a paper claim to the addresses provided on the member's identification card or the ones provided below:

• Humana Claims
• P.O. Box 14601
• Lexington, KY 40512-4601

Valid National Provider Identifiers are also recommended for paper claims. This is because paper claims that do not have the required NPIs may be denied or subject to adjudication delays. 

Aside the above-mentioned methods, Humana also supports the submission of reimbursement claims via the Humana Access Portal. This is the preferred method of requesting for reimbursement. 

This is because reimbursement requests submitted via this method are received faster and processed sooner than other methods. This method also does not require a claim form. 

To submit a reimbursement request through the Humana Access portal via the homepage or Humana Access Spending Accounts, go to the “Claims” tab and click on “Claim Activity “. 

Next, click on “Submit Claim” and follow the onscreen instructions to complete the process. 

When submitting claims you must take note of the right DME modifiers considered reimbursement Modifiers. DME Modifiers are an important part of Medical billing and are used to provide additional information about procedures, services, or supplies provided to patients. 

DME modifiers help clarify the nature of the service provided and ensure accurate reimbursement. While modifiers can be alphabetic, numeric, or a combination of both, Humana uses 2 digits for Medicare purposes. 

Durable medical equipment (DME) modifiers are used in medical billing to provide additional information about procedures, services, or supplies provided to patients. They are an important part of the DME billing process, as they can help clarify the nature of services provided and ensure accurate reimbursement. 

Humana considers the DME modifiers below as reimbursement modifiers for prosthetics and orthotics and helps in identifying new, used, or rented equipment. 

• Modifier NU: new equipment
• Modifier RR: rented equipment
• Modifier UE: purchase of used equipment

All claims must be submitted with the right Modifier. Claims submitted for equipment without the appropriate reimbursement Modifier may be delayed or denied. 

Also, to avoid claim processing errors, the listed reimbursement Modifier must be billed in the primary or first Modifier field to determine the appropriate reimbursement. 

All reimbursements are based on the negotiated rate or the applicable fee schedule for claims submitted for the equipment with the valid Modifier. 

Where to Buy DME Equipment with Private Pay Before Getting Reimbursed 

Wheelchair Liberty offers DME Equipment like power wheelchairs, electric scooters, bariatric wheelchairs, patient ceiling lifts, wheelchair ramps, and much more.  Though we don’t accept insurance for payments, by following the steps and eligibility guidelines such as pre-authorization, doctor’s prescription, medical necessity, etc. you can buy from us and get reimbursed by your insurance per their rules.