In this article, we will answer the question: “Do you take/accept insurance?” We will also attempt to explain if and how your insurance carrier will help you pay for your CPAP.
Do You Bill My Insurance Company?
Currently, Respshop.com does not directly bill Medicare or private insurance carriers. We are not a participating provider with any insurance companies. However, we will provide our customers with any information needed to fill out an insurance claim form.
Customers are advised to contact their insurance prior to making a purchase at Respshop. This is to ensure their out-of-network benefits will cover purchases made from out-of-network providers.
Also, check with your insurance for documents needed from a physician to submit along with the claim form, such as:
- Copy of a prescription
- Letter of Medical Necessity
- Medical Certification
- Pre-Authorization letter/number
Please also ask about the yearly deductible for your plan. In some cases, it is cheaper to purchase a CPAP machine from Respshop than to go through your insurance after meeting your requirements, such as co-pays and deductibles.
Will My Insurance Reimburse My Purchase?
Most insurance companies will reimburse you if Medicare pays. Normally Medicare will pay 80% of the total amount; secondary insurance will pick up the 20% unless stated in their policy.
If a customer has a third or tertiary insurance, it will pick up the remainder from the secondary insurance; otherwise, the remaining amount is the customer’s responsibility.
Insurance policies vary. Be sure to check with your specific provider before making any purchases.
Helpful hints for filing from Respironics.
Below is a list of the HCPCS Codes and medicare guidelines for replacement schedule:
| HCPCS Code | Product | Replacement Schedule |
|---|---|---|
| E0601 | CPAP/APAP machine | 1 per 5 Years |
| E0470 | BiPAP machine without backup rate feature | 1 per 5 Years |
| E0471 | BiPAP-ST machine with backup rate feature | 1 per 5 Years |
| E0472 | Respiratory assist device, bi-level pressure (BiPAP) capability, with backup rate feature | 1 per 5 Years |
| E0561 | Humidifier, Non-Heated | 1 per 5 Years |
| E0562 | CPAP Heated Humidifier | 1 per 5 Years |
| A7046 | CPAP Humidifier (Water) Chamber | 1 per 6 months |
| A7029 | Replacement Pillows for Combination Oral/Nasal Mask | 1 per month |
| A7034 | Nasal Mask (mask or cannula/pillow type) | 1 per 3 months |
| A7044 | Oral Interface | 1 per 3 months |
| A7027 | Combination Oral/Nasal Mask | 1 per 3 months |
| A7028 | Replacement Cushion for Combination Oral/Nasal Mask | 1 per month |
| A7031 | Replacement Cushion for Full-Face Mask | 1 per month |
| A7032 | Replacement Cushion for Nasal Mask | 2 per month |
| A7033 | Replacement Pillow for use on Nasal Mask (cannula/pillow) | 2 per month |
| A7037 | Tubing, Standard | 1 per 3 months |
| A4604 | Tubing with Integrated Heating Element | 1 per 3 months |
| A7038 | Disposable Filter | 2 per month |
| A7039 | Non-Disposable Filter | 1 per 6 months |
| A7045 | CPAP Exhalation port with or without swivel | 1 per 6 months |
| A7035 | CPAP headgear | 1 per 6 months |
| E1399 | Miscellaneous Durable Medical Equipment Items, Components, and Accessories (items covered by insurance not listed individually); ie, hose lift, tubing brush, etc. | Varies |
Criteria to Check on with Insurance for Coverage
Find out what percentage of the cost insurance covers and what the co-pay will be.
The following information will be provided on a Respshop.com invoice:
Diagnosis/ICD-10-CM code: G47.30 Unspecified Sleep Apnea
G47.33 Obstructive Sleep Apnea (Adult) (Pediatric)
Tax ID and CPT*/HCPC* codes.
A copy of the claim form may need to be requested from the insurance company.
Below is a link to the universal claim form:
Date of Discharge or Date of Service
| Claim Submission Date | ICD Code Set Required | ICD Indicator in Field 21 | |
|---|---|---|---|
| 10/1/2012-9/30/2015 | 10/1/2012-9/30/2015 | ICD-09 | None* |
| 10/1/2012-9/30/2015 | 10/1/2015-beyond | ICD-09 | 9 |
| 10/1/2015-beyond | 10/1/2015-beyond | ICD-10 | 0 |
*Leaving this field blank, or entering a “space” will default the claim to ICD-09.
Once insurance approves the purchase, most companies only allow one year to submit a claim. Be aware insurance may deny reimbursement if you submit a request late.
Please contact Respshop.com with any questions.
Respshop
9215 151st Ave NE
Redmond, WA, 98052, USA
Tel: 866.936.3754
Fax: 866.936.3730
Email: sales@respshop.com
Insurance and CPAP FAQ
Q: How often will insurance pay for a new CPAP machine?
A: Every 5 years.
Q: Are CPAP machines and masks billable to insurance?
A: Yes, but call your insurance to confirm.
Q: If I decide to get a new machine from you, will Medicare cover it?
A: Unfortunately, we are not able to bill insurance directly. You should be able to submit for reimbursement through your insurance company.
Q: How long does it take insurance to approve CPAP?
A: It is always best to contact your insurance company to gather all the information so you can make informed choices.
Q: What qualifies you for a CPAP machine?
A: The diagnosis of Obstructive Sleep Apnea.
Q: Are CPAP machines covered by medicare?
A: CPAP machines are often covered by medicare depending on diagnosis and approval. We, however, are not registered through medicare. Private insurance may reimburse you for purchase. Always check with your insurance provider prior to buying.
Q: Will insurance cover a second CPAP machine?
A: This is highly plan specific. We strongly recommend following up with your insurance provider.
Q: How much does CPAP cost with insurance?
A: This is also highly plan-specific. Please check with your insurance provider.