DME Supplier Standard Patient Rights CMS Medicare DME, Orthotics & Prosthetics & Supplies (42 C.F.R. 424.57©). The following is an abbreviated version of the supplier standards: 1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements. 2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days. 3. An authorized individual (one whose signature is binding) must sign the application for billing privileges. 4. A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs. 5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment. 6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare-covered items that are under warranty. 7. A supplier must maintain a physical facility on an appropriate site. 8. A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation. 9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, or cell phone is prohibited. 10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations. 11. A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business. 12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare-covered items, and maintain proof of delivery. 13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts. 14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries. 15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries. 16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item. 17. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier. 18. A supplier must not convey or reassign a supplier number; i.e. the supplier may not sell or allow another entity to use its Medicare billing number. 19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility. 20. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it. 21. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations. 22. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals). Implementation date – October 1, 2009 23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened. 24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare. 25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation. 26. Must meet the surety bond requirements specified in 42 C.F.R. 424.57©. Implementation date – May 4, 2009 27. A supplier must obtain oxygen from a state-licensed oxygen supplier. 28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f). 29. DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers. 30. DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions. Please be sure to respond to any insurance carrier requests regarding the products you receive. If you do not respond, you will be billed. Our billing office is available to help you get your claims paid. They can be reached at 1-918-528-3870. Thank you. Patient’s rights are further described below and are printed on the back of all agreements and POD documents: x Receive services without regard to race, creed, gender, age, handicap, sexual orientation, veteran status or lifestyle. – For a language assistance free of charge, please email email@example.com x Considerate, courteous, respectful and dignified treatment (care) by all National Healthcare Partners and its affiliated entities employees. x Knows charges for services including co-insurance and/or deductible due by patient including disclosure of all charges and payment arrangements. x The right to be informed when an insurance company denies any product(s) and reason(s) why. x Receive product information and protocol of our products. Access your patient records. x Have available and reasonable access to “fitting time”/service during normal business hours. x Review the records pertaining to his/her medical care and to have the information explained or interpreted as necessary, except when restricted by law. x The use of patient information will occur within strict accordance to HIPAA guidelines. Release of patient records will only occur with the patient’s consent or where permitted by law. Fulfillment of patient request to Review and/or receive a copy of his/her patient record will occur in a timely manner. x The right to consent to or decline to participate in proposed research studies affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent. x Fulfillment of patient request for organization ownership and control, and liability insurance will occur upon request and in a timely manner. x Be notified of treatment options, transfers, when and why care will be discontinued. x Receive and access services consistently and in a timely manner in accordance with the organization’s stated operational policy. x Receive information on grievance procedures which includes contact name, phone numbers, hours of operation, how to communicate problems to National Healthcare Partners and its affiliated entities x Document a response from National Healthcare Partners and its affiliated entities regarding investigation and resolution of the grievance. x Be advised of the availability, purpose and appropriate use of State, Medicare and Joint Commission hotline numbers. x Receive information concerning how to report complaints and adverse events. x Refuse treatment and be informed of potential results and/or risks. National Healthcare Partners and its affiliated entities x Education, instructions and requirements for continuing care when any services of National Healthcare Partners and its affiliated entities are discontinued. Patient’s right to be fully informed orally and in writing of the following before care is initiated: x Accurate information about previous treatments, equipment and care. x Services/products and equipment available directly or by contract. x Accurate insurance information is given. x Billing policies, payment procedures and any changes in the information provided within 15 days from the date that the organization is made aware of change. x Names and professional qualifications of the disciplines that will provide care and the proposed frequency of visits/service. x Their right to participate in the plan for care and/or any change in the plan before it is made. x Provide National Healthcare Partners and its affiliated entities with information about their expectations of and satisfaction of equipment and organization. x Follow policies and procedures set by organization. x Ask questions about their services or what they are expected to do. x Follow instructions about the use of equipment and express any concerns about their ability to follow the instructions. x Accept their share of responsibility for the outcome of care, treatment, or services if they do not follow the instructions about the use of the equipment or services. Discrimination is Against the Law (Section 1557 Notice of Non-Discrimination) National Healthcare Partners (NHCP) and its affiliates complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. NHCP & Affiliates does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. NHCP & Affiliates: – Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters, Written information in other formats (large print, audio, accessible electronic formats, other formats) – Provides free language services to people whose primary language is not English, such as: Qualified interpreters, Information written in other languages If you need these services, contact Amy Barfield firstname.lastname@example.org 918-528-3870. If you believe that NHCP & Affiliates has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Christopher Parks, Director, 8660 S Peoria Ave, Tulsa, OK 74132, Ph: 918-528-3870, fax: 918-518-6462. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Amy Barfield 918-528-3870 is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201. Ph: 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Patient Acknowledgement & Authorization to Assignment of Benefits (PA/AOB) I acknowledge receipt of the item(s) noted above. I request that payment of authorized insurance be made on my behalf to NDM and its Assigns for products & services that they provide to me. I further authorize a copy of this agreement to be used in place of the original to release to payers any information needed to determine these benefits or compliance with current healthcare standards. I understand that I am financially responsible for my health insurance deductable, coinsurance, copayments or non-covered services. I acknowledge receiving instruction, have demonstrated or verbalized my understanding in the proper use and care of the equipment or supplies received today described on this document and will follow them. I acknowledge receipt & understand the company patient information privacy notice and that all information on this document is correct.