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Home Medical Equipment

Protocol for ordering HME Products: Oxygen

  1. It is important to start the process with a phone call. Call 800-660-3420 or Madison West HME: 608 276-3420.
  2. Please have the following information available before you call:
    • Patient’s name and DOB
    • Patient’s height and weight
    • Patient’s address and phone number (home, work, cell)
    • Emergency contact name and phone number
    • If in hospital or long term care center, room number and the expected date of discharge (NOTE: delivery of item needs to be within 48 hours of discharge from a skilled facility to be reimbursed)
    • Primary and secondary insurance (including type, group and member number, and insurance customer service number)
    • Ordering physician and/or physician who will be signing the CMN
    • Facility name and phone number of the person making the referral
  3. To order oxygen, it is important to have the following information:
    • Patient’s diagnosis*
    • Info regarding ABG or Oximetry test*
      1. Name of facility and address where the test was performed
      2. Date of test
      3. Test results:
        At rest: PO2______ or SAT______%
        During sleep: PO2_______ or SAT______%
        During exercise: SAT at rest______% , SAT during exercise:____%,
        Sat with O2 during exercise ___%
    • Highest flow rate prescribed:______ liters per minute (LPM)
      If greater than 4 LPM, needs to have ABG or SAT levels while on 4 LPM
    • If PO2 is between 56-59 or SAT 89% or higher,
      1. Does the patient have dependent edema d/t CHF or cor pulmonale or pulmonary hypertension
      2. Have hematicrit >56%
    • Is a portable system required (will not be covered if patient only needs at night).
    • Length of time oxygen will be needed.
    • Has the patient ever had oxygen in the past? Previous provider?
  4. Once the phone call is made to the customer service rep, he/she will give you a fax number to fax the prescription. The prescription should have the name of the patient and the date and read: “O2 at ____LPM continuous/ambulation/at night via nasal cannula/mask.”
  5. The Customer Service Rep will fill out the CMN (for Medicare) via mail for physician signature. Oxygen orders are proceed SAME DAY unless specified.

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