United States Insurance Information
On the tabs below, you will find a breakdown of specific insurance forms and related information. Each section provides some facts and answers some of the most commonly asked questions about insurance reimbursement.
Reimbursement Quick Facts:
Downloads:
HCPCS Product Code(s):
Since ostom-i Alert Sensor does not yet have a permanent HCPCS code assigned, a miscellaneous A-Codes such as:
- A4421 Ostomy Supply; miscellaneous OR
- A9280 Alert or Alarm Device, Not Otherwise Classified:
- CMS-1500 form, section 24D, if billing in the physician's office.
- CMS-1450(UB04), section FL44, if billing under the Hospital OPPS (Outpatient Prospective Payment System).
Product Name:
- ostom-i Alert Sensor
- CMS-1500 Form. section 19 or 24A (Shaded Area)
- CMS-1450 (UB04) Form – section FL43
National Drug Code (NDC):
- 66741-0000-10
When billing Medicare:
- Must submit to the appropriate DME Intermediary (MAC):
- CGS Administrators, LLC
- National Government Services (NGS), Inc.
- NHIC
- Noridian Administrative Services
Reimbursement Quick Facts:
HCPCS Product Code(s):
Since ostom-i Alert Sensor does not yet have a permanent HCPCS code assigned, a miscellaneous A-Codes such as:
- A4421 Ostomy Supply; miscellaneous OR
- A9280 Alert or Alarm Device, Not Otherwise Classified:
- CMS-1500 form, section 24D, if billing in the physician's office.
Product Name:
- ostom-i Alert Sensor
- CMS-1500 Form. section 19 or 24A (Shaded Area)
National Drug Code (NDC):
- 66741-0000-10
When billing Medicare:
- Must submit to the appropriate DME Intermediary (MAC):
- CGS Administrators, LLC
- National Government Services (NGS), Inc.
- NHIC
- Noridian Administrative Services
Reimbursement Quick Facts:
Downloads:
HCPCS Product Code(s):
Since ostom-i Alert Sensor does not yet have a permanent HCPCS code assigned, a miscellaneous A-Codes such as:
- A4421 Ostomy Supply; miscellaneous OR
- A9280 Alert or Alarm Device, Not Otherwise Classified:
- CMS-1450 (UB04), section FL44, if billing under the Hospital OPPS (Outpatient Prospective Payment System).
Product Name:
- ostom-i Alert Sensor
- CMS-1450 (UB04) Form – section FL43
National Drug Code (NDC):
- 66741-0000-10
When billing Medicare:
- Must submit to the appropriate DME Intermediary (MAC):
- CGS Administrators, LLC
- National Government Services (NGS), Inc.
- NHIC
- Noridian Administrative Services
DME - Universal Claim Form:
Download:
Universal Claim Form:
Tips to help you complete the DME Claim Form
Use this Claim Form to request payment from your Insurance Company for reimbursement for your DME device you've already paid for with a credit card, cash or check.
You can also use this Claim Form to request reimbursement to the supplier of your DME device.
You only need to fill out this form if your health care professional isn't filing the claim for you.
Even if your DME supplier is out-of-network with your Insurance Company, your DME supplier can still file the claim for you.
Your Insurance Company must receive your claim within 90 days from the date you received your DME device, unless your plan or state laws allow for more time.
What will your DME proof of purchase should include:
- Name of Provider or Organization that provided the Ostom-i device
- Name of patient
- Date of service Ostom-i device was placed
- Description of Ostomi-i device
- Total Charge of Ostom-i device
Things to Remember:
- Attach a copy of your proof payment to this claim form
- Make a copy of this claim form, claim details and receipt(s) to keep for your records.
After processing your claim, you'll receive an Explanation of Benefits (EOB).
The EOB explains the charges applied to your deductible (the amount you pay for covered services before your plan begins to pay) and any charges you may owe the provider.
Please keep your EOB on file in case you need it in the future.