Common questions about DME eligibility checks and claims

Durable medical equipment (DME) billing works differently from other healthcare billing.

Most DME claims aren't tied to a patient visit. A physician or other practitioner orders the equipment. A separate company, the DME supplier, fills the order from a referral and bills the payer.

There are other quirks. One equipment order doesn't mean one claim. Suppliers often bill for rented equipment, like hospital beds, every month. The patient's coverage can change between claims. So suppliers check eligibility before each rental month.

Some coverage rules also depend on the patient's history with other suppliers. For example, Medicare usually won't pay for a CPAP device if another supplier provided the patient with one three years ago. That history isn't in the eligibility response.

This guide answers common questions about building eligibility checks and claim workflows for DME using Stedi.

How can I find a patient's coverage from an incomplete referral?

If the referral doesn't include the patient's payer, start with an insurance discovery check. You can run one using just demographic information, like first and last name, date of birth (DOB), and optionally the patient's state and Social Security Number (SSN).

For patients who are likely covered by Medicare, such as those 65 or older, use a Medicare Beneficiary Identifier (MBI) lookup instead.

Stedi offers two types of MBI lookups: one with the patient's SSN and one without. If you have the patient's SSN, start with that version.

You can also run MBI lookups as part of insurance discovery checks. To do this, enroll the provider with the Stedi insurance discovery payer (payer ID: DISCOVERY).

Tip: If you're using the Stedi portal, you can use an Agentic Discovery check to find coverage in one step. It runs an eligibility check, tries to recover the check if it fails, and then runs an insurance discovery check if needed.

Which STCs should I use for DME eligibility checks?

In an eligibility request, a Service Type Code (STC) tells the payer what kind of benefits you're asking for. The payer also uses STCs in the response. But not every payer supports the same STCs.

Testing is the best way to find out which STCs work for each payer. Our docs cover general STC testing tips. Here's specific guidance for DME suppliers.

Step 1. Start with STC 30 (Health Benefit Plan Coverage)

Begin with STC 30 as your baseline. You'll use the response to test whether the payer supports more specific STCs.

Many payers fall back to their STC 30 response if you submit an STC they don't support.

You'll usually need to send a DME-specific STC to get related benefits. Payers aren't obligated to return DME benefits under STC 30.

CORE-certified payers must return benefits when you send STC 12 (Durable Medical Equipment Purchase) or 18 (Durable Medical Equipment Rental), and the plan covers the service. See the CAQH CORE required response set.

Step 2. Test DME-specific STCs

Try one or more STCs from the following table.

Start with DM. It's the most widely supported DME STC. A DM request often returns benefits for 12 and 18 too.

Tip: Avoid using STC DS (Diabetic Supplies) for DME checks. Payers generally don't use this STC for DME.

Send one STC per eligibility request. Many payers don't support multiple STCs in a single check. If you use multiple STCs, some payers may reject the request. Others may return a default response or only use the first STC provided.

Step 3. Compare the eligibility responses

Compare the payer's responses for STC 30 and the DME STC you tested.

If an STC returns DME coverage that STC 30 didn't, the payer supports that STC. Use that STC in future eligibility checks for that payer.

Repeat the process for each payer. You can't assume STCs that work for one payer apply to another.

Tip: Use a script to loop and diff

You can script your eligibility requests to speed up the testing process. Specifically, you should loop through STCs you want to test and compare the responses against the baseline STC 30 response for the same patient. For more tips, see our STC testing docs.

Can I use HCPCS codes in my eligibility requests?

In most cases, no. Most medical payers don't return benefits for Healthcare Common Procedure Coding System (HCPCS) or other procedure codes, like E0601 for a CPAP device. Some reject the request.

Unless you know the payer supports procedure codes in eligibility requests, send an STC instead. To find the STC for a HCPCS code, use our CPT/HCPCS to STC lookup tool.

Do payers reliably return DME benefits in eligibility responses?

Yes. Most payers reliably confirm whether the patient has active coverage. DME cost share, like co-insurance and deductibles, is less reliable. We cover two common scenarios below.

DME benefits are missing

Some payers ignore the STC you send and return benefits for the same fixed set of STCs, no matter which STC you request. The check succeeds with no errors.

The only sign is that the response doesn't include any benefits for the DME STC you requested. In responses from Stedi's JSON Real-Time Eligibility Check API, each benefit entry lists its STC in the service object.

{
  "plans": [
    {
      "benefits": {
        "coInsurance": [
          {
            "percent": "0.2", // 20% co-insurance
            "service": {
              "system": "STC",
              "value": "30", // Returned for STC 30, not the DM you requested
              "definition": "Health Benefit Plan Coverage"
            },
            ...
          }
        ],
        "deductible": [
          {
            "amount": "1500",
            "service": {
              "system": "STC",
              "value": "30", // Also STC 30. No entries for DM, 12, or 18
              "definition": "Health Benefit Plan Coverage"
            },
            ...
          }
        ],
        ...
      }
    }
  ]
}

In these cases, treat the DME benefit as unknown, not as $0. If a payer consistently leaves out DME benefits, contact us with an example. We work with payers to fix their responses.

If you need the benefits immediately, try checking the payer's portal or calling the payer by phone.

Co-insurance of 0%

Some payers send a co-insurance percentage of 0 when they don't have a DME-related value to report. The placeholder can look the same as real full coverage.

For example, the following JSON Real-Time Eligibility Check API response shows a coInsurance.percent of 0. It's unclear whether this is a placeholder:

{
  "plans": [
    {
      "benefits": {
        "coInsurance": [
          {
            "percent": "0", // 0% – real, or a placeholder?
            "service": {
              "system": "STC",
              "value": "12",
              "definition": "Durable Medical Equipment Purchase"
            },
            ...
          }
        ]
      }
    }
  ]
}

Before you quote 0% co-insurance to a patient, check these signals:

• Free-text notes. Look in the entry's messages for phrases like "AFTER DEDUCTIBLE" or "MANAGED SEPARATELY".

• Network indicators. An entry with no network.indicator, or with IN_AND_OUT_OF_NETWORK, can be less reliable than separate IN_NETWORK and OUT_OF_NETWORK entries.

• The out-of-pocket maximum. If it's higher than the deductible, the patient usually pays some cost share after the deductible.

Can I find the carveout admin for DME benefits in eligibility responses?

In many cases, yes. Payers often carve out DME benefits to another entity, called a carveout administrator (admin).

Many payers return the carveout admin's information in a contactFollowingEntityForInformation entry. The entry's relatedEntities array includes a name and contact information, but doesn't include DME cost share.

{
  "plans": [
    {
      "benefits": {
        "contactFollowingEntityForInformation": [
          {
            "service": {
              "system": "STC",
              "value": "DM",
              "definition": "Durable Medical Equipment"
            },
            "relatedEntities": [
              {
                "type": "THIRD_PARTY_ADMINISTRATOR",
                "name": {
                  "organization": "ACME DME BENEFITS"
                },
                "contacts": [
                  {
                    "phoneNumbers": ["1234567890"]
                  }
                ]
              }
            ],
            ...
          }
        ]
      }
    }
  ]
}

To get the DME benefits, send a second eligibility check to the carveout admin.

The carveout admin may return the member ID in a different format. Keep the member ID you submitted for your claims. For more details, see our carveout benefit docs.

Can an eligibility check tell me about same or similar equipment?

No. A same or similar check looks for DME the patient already received, including from other suppliers.

Same or similar checks are important for Medicare patients. Medicare doesn't pay for a DME item if the patient already has the same or a similar item within its reasonable useful lifetime.

Medicare eligibility responses don't include the claims history needed for a same or similar check. Instead, check the provider portal for the patient's DME Medicare Administrative Contractor (MAC). DME MAC portals show a patient's Medicare claims history, including same or similar items.

Can an eligibility check tell me how many rental months a patient has used?

No. Eligibility responses don't typically include rental months used or remaining. They also don't include the rules for when a rental converts to a purchase. To get these details, check the payer's portal or call the payer.

Can an eligibility check tell me if DME requires prior authorization?

Sometimes. In JSON Real-Time Eligibility Check API responses, check the priorAuthIndicator field on the benefit entry for the DME STC.

{
  "plans": [
    {
      "benefits": {
        "coInsurance": [
          {
            "percent": "0.2",
            "priorAuthIndicator": "REQUIRED", // Prior authorization is required
            "service": {
              "system": "STC",
              "value": "18",
              "definition": "Durable Medical Equipment Rental"
            },
            ...
          }
        ]
      }
    }
  ]
}

Payers can also add notes that clarify the requirement in the entry's messages:

{
  "plans": [
    {
      "benefits": {
        "coInsurance": [
          {
            "percent": "0.2", // 20% co-insurance
            "network": {
              "indicator": "IN_NETWORK" // Applies to in-network services
            },
            "service": {
              "system": "STC",
              "value": "12",
              "definition": "Durable Medical Equipment Purchase"
            },
            "messages": [
              "PRIOR AUTHORIZATION REQUIRED FOR POWER WHEELCHAIRS."
            ],
            ...
          }
        ]
      }
    }
  ]
}

For Original Medicare, the Centers for Medicare & Medicaid Services (CMS) sets DME prior authorization requirements in its Required Prior Authorization List, not the eligibility response. The list includes items like power mobility devices and some orthoses, by HCPCS code.

Where do I send Medicare DME eligibility checks and claims?

They go to different places depending on the transaction.

Original Medicare eligibility checks

Eligibility checks for Original Medicare go to CMS (payer ID: CMS). That includes eligibility checks for DME services.

Suppliers must complete transaction enrollment with CMS to run eligibility checks.

Original Medicare claims

DME claims go to the DME MAC for the patient's state, not the supplier's state. To find the current DME MAC for a state, see CMS's Who are the MACs. For more about MACs, see How to find the right payer for Medicare claims.

A supplier must complete transaction enrollment to submit claims or receive Electronic Remittance Advice (ERAs) from a DME MAC.

Medicare Advantage eligibility checks and claims

For Medicare Advantage plans, send both eligibility checks and claims to the plan's payer.

Get started with Stedi

If you're building eligibility or claims workflows for DME, Stedi can help.

To get started, sign up for a free sandbox account. It takes less than two minutes. No credit card is required.

When you're ready, upgrade to production on our pay-as-you-go plan. There are no monthly minimums or setup fees. You only pay for the transactions you use.