1. (a) Billing Procedure

   1. (1) Form H.C.F.A. 1500 "Health Insurance Claim Form" is used to bill for oxygen therapy. The bill is mailed to the Department's claims processing agent.
   2. (2) All claims submitted for payment which include prior authorized items must include the authorization number from the current authorization.
   3. (3) All claims submitted for services not requiring prior authorization must include the name of the prescribing physician.
   4. (4) The provider shall enter its usual and customary charge on the claim form.

2. (b) PaymentPayment for oxygen therapy will be made at the lower of:

   1. (1) the usual and customary charge to the public, or(2) the amount as contained in the fee schedule as published by the Department, or(3) the amount billed by the provider.
3. (c) Payment Rate for Oxygen TherapyThe Commissioner of Income Maintenance establishes the oxygen therapy rate as contained in the Department's fee schedule.

4. (d) Payment Limitations

   1. (1) All prices quoted for equipment and services include delivery costs fully prepaid by the provider, F.O.B. destination; no additional charges are to be made for packing, shipping, or delivery to the recipient.
   2. (2) If the estimated cost of repairs to any equipment exceeds replacement cost, the item will be replaced.
   3. (3) Payment for repairs or replacement of equipment which is purchased by the Department is contingent upon any unexpired manufacturers or dealer warranties. The supplier must first utilize existing warranties covering such servicing, repairs, and replacement.

   4. (4) The cost of oxygen therapy includes all services and supplies necessary including, but not limited to:

      1. (1) installation and/or set up of prescribed equipment;
      2. (2) teaching and training the recipient, recipient's family, and long-term care facility professional staff in the use and care of the equipment as shall be necessary;
      3. (3) oximetry test.
      4. (5) The rental fee for the delivery of oxygen therapy includes a nasal cannula, mask, and disposable humidifier as needed.

(Effective May 27, 1992)