Insurance and Billing Information

As a courtesy to our patients, PPS Orthotic & Prosthetic Services makes every effort to file all patient insurance, Medicare and Medicaid claims. Under certain circumstances, the patient may be responsible for part or all of the cost of their orthotic or prosthetic device. A signed physician order/scrip is required.

Insurance companies such as Amerigroup, worker's comp, some Medicare HMO's, as well as some other companies require pre-authorization and most take a minimum of two weeks to get a response. We are now giving patients an option of either waiting for pre-authorization or taking the device as soon as we can have it ready for fitting.

Acordia Alliant Blue Cross of GA
Blue Cross of TN
Cariten
CIGNA
GA Medicaid
TN Medicaid
Medicare All Tennessee
TNCare

Other insurance companies may be accepted, for assistance in obtaining preauthorization or additional information contact Dianne Brown, Billing Administrator or Anissa Stokes, Assistant Billing Administrator at 423-697-0057.

CMS (Centers for Medicare and Medicaid) coverage is dictated by law and regulated by the PPS or Prospective Payment System. This system was implemented to prevent fraud and abuse and over-utilization in the provision of primarily DME (Durable Medical Equipment) but also affects the provision of orthotic services for persons that are in-patients in hospitals, rehabilitation centers, nursing homes and other health care facilities. Patients may have either Part A (in-patient, hospital)
coverage, Part B (out-patient coverage) or both.

All prosthetic services (artificial limbs) are exempt from PPS regulations for individuals covered under Part B and as such are able to be provided to patients in any of the health care settings described above.

PART A: Patients who are in-patients in a healthcare facility and covered under Part A of Medicare are eligible for orthotic and prosthetic services ONLY if the healthcare facility provides a purchase order for the services or if the patient agrees to pay for the services.
PART B: Patients with both Part A and Part B, who are in-patients in an acute healthcare facility (hospital, etc.) but covered under Part A, will also require a purchase order from the healthcare facility in order to receive orthotic services provided prior to 48 hours before their discharge. (As mentioned earlier, prostheses can be provided in this setting, and CMS billed by the provider under Part B, at no cost to the healthcare facility)

Note: For the above patients, orthotic services delivered within 48 hours of discharge, on the discharge date, or after the discharge date are billed by the provider under part B and at no cost to the healthcare facility. The patient is responsible only for the normal co-payment of the Medicare allowable charges under CMS part B guidelines.

PART B Nursing Home Patients: Patients who enter nursing homes have 100 days of Part A coverage per year. During this time, provision of orthotic services can ONLY occur if the healthcare facility provides a purchase order. After the 100 days, for patients who qualify as “skilled”, the normal 48 hour window applies and orthotic services are billed by the provider under part B and at no cost to the healthcare facility. The patient is responsible only for the normal co-payment of the Medicare allowable charges under CMS part B guidelines. For “resident” Part B patients, no restrictions on services apply. (Again, prostheses can be provided at any time, without cost to the healthcare facility.)

All consults require a written order from the physician or therapist and must be placed in the patient’s chart. After evaluation, a detailed, CMS compliant prescription, will be sent to the physician for his/ her signature. Consults can be faxed to our office, along with face sheet to begin the process.

PPS Orthotic and Prosthetic Services will evaluate a patient and make a recommendation to the physician or physical therapist on treatment options at no cost to the patient or to the facility.

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Insurance and Billing Information