DME with multiple parts must have each part itemized on the request form. Providers may attach an itemized listing of Health Common Procedure Coding System (HCPCS) and max fees. DME that does not have a maximum fee determined by the Health and Human Services Commission (HHSC) are manually priced at the manufacturer’s suggested retail price (MSRP) minus 18%, discount determined by HHSC. If an item is manually priced, the MSRP must be submitted with the appropriate procedure code for consideration of rental or purchase. The physician’s signature is not required on additional itemized lists.

The revised form is effective September 8, 2008, and will also be published in the February 2009 CSHCN Services Program Provider Bulletin No. 69. Click here to access the revised form.