1352 Combermere Dr. Suite A Troy, MI 48083

T: 248-632-1700 F: 248-435-8602 | NexusMedicalEquipment.com

DME Order Package

Just as your company cares for its patients, so too should the DME you choose to work with. Here at Nexus, we

want to extend that caring feeling you give your patient throughout our delivery process.

We have developed an expedited ordering process which eliminates the number of follow up calls needed and

increases the likelihood of getting the equipment covered by insurance. The attached package contains

everything your staff needs to order equipment from us including a quick-pick prescription form, chart note

verbiage guide and an incontinence order form.

Now Powered by Brightree!

Nexus is now using Brightree, a world-class medical billing application that is integrated into the back-end

systems of all major insurance companies and equipment manufacturers. This provides a faster, more accurate

billing process that allows for quicker delivery. Our purchasing, inventory, warehouse and delivery routing have

also been upgraded through Brightree so that we may better manage a higher volume of referrals.

Why Nexus?

Nexus Medical Equipment is unique because while we are a fully accredited DME provider, our focus is

centered on home safety. We provide free home safety inspections as well as mobility home modifications like

entrance and threshold ramps, grab bars and handrails and even non-permanent stability solutions that offer

both safety and comfort. We are also partnered with 2 major building companies who can do the more

extensive home modifications that are sometimes required.

Nexus makes it easy and convenient for your staff to provide your patients with everything they need for going

home by providing both the medical equipment and home modifications.

Please check us out at NexusMedicalEquipment.com

1352 Combermere Dr. Suite A Troy, MI 48083

T: 248-632-1700 F: 248-435-8602 | NexusMedicalEquipment.com

NEXUS CAN ACCEPT THE FOLLOWING INSURANCE PLANS

If a client has more than one insurance plan, such as Medicare and Blue Cross and Blue Shield of Michigan,

the entire charge or co-payment may not be due. In most situations, the secondary insurance will cover a

portion of the co-payment; the remaining balance will vary depending on the type of secondary plan.

For referral information or a description of our full range of services, call 248-632-1700

Nexus can accept a variety of health plans including, but not limited to, the following:

• AARP

• Accident Fund

• Aetna (Most Plans)

• Allegan Healthcare Group (BCBS)

• Allstate

• BCBS PPO Plans

• BCBS Federal Employee Program (FEP)

• BCBS Medicare Plus Blue (PPO)

• BCBS Blue Preferred Plus PPO

• BCBS Physician Choice PPO

• BCBS State of Michigan Health Plan PPO

• BCBS Traditional

• BCBS GM Connected Care Plans (ConnectedCare Henry Ford Health System and ConnectedCare

Ascension Genesys)

• BCBS Trinity Health Network PPO

• Blue Care Network

• BCN Advantage

• Blue Cross Premier PPO

• Blue Cross PPO Premier Gold

• Blue Cross PPO Premier Silver Extra

• Blue Cross PPO Premier Silver

• Blue Cross PPO Premier Silver Off Marketplace

• Blue Cross PPO Premier Silver Saver

• Blue Cross PPO Premier Bronze Extra

• Blue Cross PPO Premier Bronze Saver

• Blue Cross PPO Premier Bronze

• Blue Cross PPO Premier Value

2

• Carson City Hospital (BCBS)

• Challenge MFG PPO Health Plan (BCBS)

• Chippewa County War Memorial Hospital (BCBS)

• Cofinity

• Community Health Center Branch County (BCBS)

• Helen Newberry Joy Hospital (BCBS)

• Henry Ford Health System (BCBS)

• Humana PPO

• Hurley Medical Center (BCBS)

• Kellogg National Plans (BCBS)

• Mary Free Bed Hospital (BCBS)

• McLaren Health Care (BCBS)

• Medicaid

• Medicare

• Memorial Health Care Center (BCBS)

• Metro Health BCBSM Plans

• Michigan Healthcare Professionals (BCBS)

• North Ottawa Community Health System (BCBS)

• Northstar Health System (BCBS)

• OSF Healthcare Missouri Partners (BCBS)

• Otsego Memorial Hospital (BCBS)

• Priority Health (Most Plans)

• Progressive Auto Claims

• Schoolcraft Memorial Hospital (BCBS)

• Sparrow Hospital (BCBS)

• State Farm Insurance

• Sturgis Hospital (BCBS)

• Tricare

• United Health Care Community Plan

• United Health Care - Ford Employees

• United Health Care - GM Employees

• United Health Care PPO

• University of Michigan PPO (BCBS)

• University of Michigan CMM/Traditional (BCBS)

• West Branch Regional Medical Center (BCBS)

Ready to start sending us referrals?

Call 248-632-1700 today for your personalized Quick Order Package that includes everything you need to make

ordering equipment for your patients fast and convenient.

1352 Combermere Dr. Suite A Troy, MI 48083

T: 248-632-1700 F: 248-435-8602 | NexusMedicalEquipment.com

How to Order:

1. Fill out our quick-pick prescription form.

2. Add the relevant verbiage from our verbiage guide to the patient’s chart notes.

NOTE: USING THIS VERBIAGE WILL INCREASE THE LIKLIHOOD OF THE EQUIPMENT BEING COVERED BY THE

PATIENT’S INSURANCE.

3. Fax the prescription, face sheet and chart notes to 248-435-8602.

4. Nexus will fax back a detailed written order (DWO) which needs to be signed by a PECOS certified physician,

physician’s assistant or nurse practitioner.

5. Fax the signed DWO back to us.

That’s it! Your order will be processed and delivered quickly and accurately.

One Last Note

This package is intended to help us expedite deliveries to your patients, but you are always welcome to use

your own ordering process. Nexus will work with you in every way to ensure success and always has the

patient’s happiness in mind.

Nexus Home Medical Equipment1352 Combermere Dr. Ste. ATroy, MI 48083Ph 248.632.1700 ��� ������������NexusMedicalEquipment.com

Prescription: Durable Medical Equipment (DME)

PHYSICIAN INFORMATION Attending Physician Signature _________________________Printed Attending Physician Name _____________________Attending Physician NPI Number _______________________Signature Date _____________________________________Facility Name ______________________________________Form Completed By _________________________________Phone Number _____________________________________

PATIENT INFORMATION Patient Name ______________________________________Patient Date of Birth ________________________________Patient Cell Phone Number ___________________________Patient E-mail ______________________________________

Patient Height___________ Patient Weight______________Anticipated Discharge Date _______________________________

Step 1 | phySician !b5 patient information (pleaSe print legibly)

.

STEP 3 | DME PRESCRIPTION

mobility Standard Walker No Wheels (E0135) With Wheels (E0143)

q Rollator (4-Wheeled Walker) (E0143)q Manual Wheelchair with Swing Away Footrests 16"|18"|20"|22"q Manual Wheelchair with Elevated Footrests 16"|18"|20"|22" q Wheelchair Cushion Package (Seat & Lumbar) q Wheelchair Safety Package (Seat Belt, Anti Tip, Brake Extender)q Cane (E0100) Quad Cane (E0105)q Crutches (E0114) Hip Replacement Kit (E1399) q Platform Attachments (E0153) q Right q Left q Hospital Bed With Trapeze (E0910)q Gel Overlay (E0196) Low Loss Air Mattress (E0277)q Transfer Board (E0705) Patient Lift (E0630) q Knee Walker (E0118)

Bathroom Safety Tub Transfer Bench (E0247)

q Shower Chair with Back (E0240) q Shower Chair without Back (E0240) q Raised Toilet Seat (E0244) q Raised Toilet Seat with Arms (E1399) q Drop Arm Commode (E0165 and Medicaid Code E1399) q Commode - Bedside / 3 In One (E0163) q Other __________________________

length of need Please note: this information is required. Length of need _____________ Number of Months (1 to 99 months | 99 months = lifetime)

PATIENT QUESTIONS (optional)1. Has this patient had this equipment before? q no

If yes, when? ___________________________________

2. Is this patient room/bed bound? q no

3. Is the patient’s bathroom located on a floor they can access? q yes q no

4. Does the patient have a mobility limitation that significantlyimpairs his/her ability to participate in one of more Mobility Related Activities of Daily Living (MRADLs) – such as toileting, feeding, dressing, grooming and bathing in the home? q yes q no If yes, please explain: _________________ ______________________________________________

5. Are there any other conditions that limit the patient’s ability to participate in MRADLs at home? q yes q no If yes, please list applicable conditions: ______________________________________________

Step 2 | diagnoSiS (required)

q Primary ______________________ q Secondary _______________________ q Other _________________________

STEP 4 | FAx Fax this form and patient demographic sheet which includes insurance information to Nexus Medical Equipment at 248.435.8602.

yes q

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Nexus Home Medical Equipment 1352 Combermere Dr. Ste. A Troy, MI 48083 Ph 248-632.1700 Fax:248.435.8602 NexusMedicalEquipment.com

Chart Notes: Chart Note Verbiage Guide

If applicable, please include the verbiage below in the chart notes or as an addendum for each piece of equipment. This verbiage fulfills the face-to-face requirements of most insurance companies and helps ensure coverage. The chart notes or addendum should be signed by a PECOS certified physician, physician’s assistant or nurse practitioner: LIGHTWEIGHT WHEELCHAIR: (K0003 WEIGHT CAPACITY 250 LBS OR LESS) THE PT HAS MOBILITY LIMITATIONS THAT CAN’T BE SOLVED BY THE USE OF CANE/WALKER. PT CANNOT PROPEL A STANDARD WHEELCHAIR BUT DOES HAVE SUFFICIENT UE STRENGTH TO PROPEL A LIGHTWEIGHT WHEELCHAIR IN THE HOME TO COMPLETE MRADLs. PT REQUIRES SUPPORT SURFACE TO PREVENT SKIN BREAKDOWN DUE TO COMPROMISED CIRCULATORY STATUS/SENSORY PERCEPTION.

STANDARD WHEELCHAIR: (K0001 WEIGHT CAPACITY 250 LBS OR LESS) THE PT HAS MOBILITY LIMITATIONS THAT CAN’T BE SOLVED BY THE USE OF CANE/WALKER. PT CAN PROPEL A STANDARD WHEELCHAIR IN THE HOME TO COMPLETE MRADLs. PT REQUIRES SUPPORT SURFACE TO PREVENT SKIN BREAKDOWN DUE TO COMPROMISED CIRCULATORY STATUS/SENSORY PERCEPTION.

HEAVY-DUTY WHEELCHAIR: (K0006 OR K0007 (250 POUNDS AND UP) THE PT HAS MOBILITY LIMITATIONS THAT CAN’T BE SOLVED BY THE USE OF CANE/WALKER. PT REQUIRES A HEAVY-DUTY WHEELCHAIR DUE TO WEIGHT OF __________LBS. PT REQUIRES WHEELCHAIR IN THE HOME TO COMPLETE MRADLs. PT REQUIRES SUPPORT SURFACE TO PREVENT SKIN BREAKDOWN DUE TO COMPROMISED CIRCULATORY STATUS/SENSORY PERCEPTION.

TRANSPORT WHEELCHAIR: (E1038) PATIENT CANNOT USE A CANE OR WALKER OF ANY KIND. PATIENT IS UNABLE TO SELF PROPEL A WHEELCHAIR OF ANY KIND BUT DOES HAVE A CAREGIVER WILLING TO PROPEL THE PATIENT TO AID HIS/HER WITH HIS/HER MRL’S.

HEMI WHEELCHAIR: (K0002 IF PT HEIGHT IS 5’3 OR LESS) THE PT HAS MOBILITY LIMITATIONS THAT CAN’T BE SOLVED BY THE USE OF CANE/WALKER. PT CAN PROPEL A STANDARD WHEELCHAIR IN THE HOME TO COMPLETE MRADLs. PT REQUIRES LOW SEAT TO FLOOR HEIGHT DUE TO SHORT STATUE AND SURFACES TO PREVENT SKIN BREAKDOWN DUE TO COMPROMISED CIRCULATORY STATUS/SENSORY PERCEPTION.

HOSPITAL BED (COPD, CHF JUSTIFICATION): PT REQUIRES HOSPITAL BED. THE HEAD OF BED TO BE ELEVATED MORE THAN 30 DEGREES DUE TO (COPD, CHF, RISK OF ASPIRATION – CHOOSE BEST OPTION). PILLOWS AND WEDGES HAVE BEEN RULED OUT. PT REQUIRES FREQUENT CHANGES IN BODY POSITION. PT REQUIRES SUPPORT SURFACE TO PREVENT SKIN BREAKDOWN DUE TO COMPROMISED CIRCULATORY STATUS OR SENSORY PERCEPTION.

HOSPITAL BED (PAIN JUSTIFICATION): PT REQUIRES HOSPITAL BED. PT REQUIRES POSITIONING OF BODY IN WAYS NOT FEASIBLE IN AN ORDINARY BED TO ALLEVIATE PAIN. PILLOWS AND WEDGES HAVE BEEN RULED OUT. PT REQUIRES FREQUENT CHANGES IN BODY POSITION. PT REQUIRES SUPPORT SURFACE TO PREVENT SKIN BREAKDOWN DUE TO COMPROMISED CIRCULATORY STATUS OR SENSORY PERCEPTION.

HOYER LIFT: (E0630) PT REQUIRES THE USE OF HOYER LIFT TO ASSIST IN INDEPENDENT POSITIONING AND/OR ASSIST CAREGIVERS IN PROPERLY POSITIONING THE PATIENT FOR CARE AND IS REQUIRED TO ASSIST IN LIFTING AND TRANSFERRING PATIENT SAFELY.

TRAPEZE: (E0910) PT REQUIRES THE USE OF LIFT TO ASSIST IN INDEPENDENT POSITIONING AND/OR ASSIST CAREGIVERS IN PROPERLY POSITIONING THE PATIENT FOR CARE AND IS REQUIRED TO ASSIST IN LIFTING AND TRANSFERRING PATIENT SAFELY.

GEL OVERLAY: (E0185) Patient needs to meet only ONE of the criteria below

1. The beneficiary is completely immobile – i.e. beneficiary cannot make changes in body position without assistance OR

2. The beneficiary has limited mobility – i.e. beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below

OR

3. The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.

Conditions for criteria 2 and 3 above (in each case the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface):

A. Impaired nutritional status

B. Fecal or urinary incontinence

C. Altered sensory perception

D. Compromised circulatory status When the coverage criteria for a Group 1 mattress overlay or mattress are not met, the claim will be denied as not reasonable and necessary.

1352 Combermere Dr. Suite A Troy, MI 48083

T: 248-632-1700 F: 248-435-8602 | NexusMedicalEquipment.com

NEXUS HME CPAP PRESCRIPTION – FAX TO: 248-435-8602

Patient Name:___________________________________ Date of Birth:___________________

☐ CPAP Pressure: Duration:

☐ BIPAP Pressure: Duration:

Interface:

☐ Small ☐ Full face mask q1 / 3 month x 1 year PRN A7030

☐ Medium ☐ Interface q1 / month A7031

☐ Large ☐ Cushions q2 / month A7032

☐ Size to Fit ☐ Nasal Pillows q1 / month x1 year PRN A7033

☐ Nasal Mask q1 / 3 months x1 year PRN A7034

☐ Other

Accessories:

☐ Head gear q1 /6 months qx1 year PRN A7035 ☐ Smart card

☐ Chin strap q1 / 6 months x 1 year PRN A7036 ☐ Non-disposable filters q1 / 6 mon x 1 year PRN A7039

☐ Tubing q1 / 3 months x 1 year PRN A7037 ☐ Disposable filter q2 / month x 1 year PRN A7038

☐ Substitution Permitted ☐ Climate tubing q1 / 3 months A4604

☐ Other ☐ Water Chamber q1 / 6 months A7046

Please Include:

1. Patient Demographics 3. PSG / HST

2. Face to face notes prior to sleep study 4. Oxygen Titration

Ordering Physician: _________________________________ NPI:________________________________

Ordering Physician Signature: ________________________ Date: ______________________________

1352 Combermere Dr. Suite A Troy, MI 48083

T: 248-632-1700 F: 248-435-8602 | NexusMedicalEquipment.com

24 Hour (Continuous) Oxygen Order

1. How to qualify:

a. Patient saturation of 88% or less at rest without oxygen.

• If this occurs, please move on to step 2.

b. Patient saturation of 89% or greater at rest without oxygen.

• Saturation of 89% or greater

• Saturation during exercise without oxygen should be 88% or less.

• Saturation during exercise with oxygen litre flow used to show improvement.

2. After testing is completed, we need the following documentation:

a. Demographics/Insurance

• Name

• Address

• Phone Number

• Updated insurance numbers

b. Office visit notes

• Includes the saturation of 88% or less at rest without oxygen, or the 3 saturations from the walk

test and O2 litre flow

• Notes need to be signed by the doctor

• Qualifying diagnosis

c. Script

• Patients name and full address

• Patients date of birth

• Qualifying diagnosis

• Litre flow needed

• Doctors NPI number

• Doctors signature

• Date at the top of the script and next to the signature

• The Medicaid ID number, if patient has Medicaid

NOTES:

• ALL MEDICARE PATIENTS REQUIRE A REASON FOR DIAGNOSIS. EXAMPLE: (HYPOXIA CAUSED BY COPD.)

• ALL TESTING, DOCUMENTATION AND EQUIPMENT SETUP NEEDS TO BE WITHIN 30 DAYS.

• MEDICARE LCD POLICY AVAILABLE UPON REQUEST

NEXUS OXYGEN REFFERAL REQUIREMENTS VER.1.1 REVISED 3/11/2019

Nocturnal Oxygen Order

1. How to qualify:

a. Patient must have an office visit stating the need of a pulse oximetry test.

b. Patient must have a nocturnal pulse oximetry test done.

*Patient can also qualify from a CPAP titration study (not the PSG)

2. If saturations are 88% or less we need the following documentation:

a. Demographics/Insurance

• Name

• Address

• Phone Number

• Updated insurance numbers

b. Office visit notes

• Discussing the need for nocturnal oxygen

• Notes need to be signed by the doctor

• Qualifying diagnosis

c. Script

• Patients name and full address

• Patients date of birth

• Qualifying diagnosis

• Litre flow needed

• Doctors NPI number

• Doctors signature

• Date at the top of the script and next to the signature

• The Medicaid ID number, if patient has Medicaid

NOTES:

• ALL MEDICARE PATIENTS REQUIRE A REASON FOR DIAGNOSIS. EXAMPLE: (HYPOXIA CAUSED BY COPD.)

• ALL TESTING, DOCUMENTATION AND EQUIPMENT SETUP NEEDS TO BE WITHIN 30 DAYS.

• MEDICARE LCD POLICY AVAILABLE UPON REQUEST

Referral source (i.e. physician, website) Follow-up on order status with

Best day to follow-up

Order Date

Phone

Best time to follow-up Email

Referral source name

Referral relation to patient

For Physician Use Only: Physician Stamp

Physician Stamp or Signature:

For Physician Use Only: Prescription

THIS PRESCRIPTION WILL BE FILLED GENERICALLY UNLESS PRESCRIBER WRITES ‘d a w’ IN THE BOX

Dispense As Written

Dispense 1 Month Supply 3 Month Supply

Products Diagnosis

Quantity Adult Briefs - Tabs (CASE) Small Medium Large X-Large

R33.9 Retention of urine, unspecified R39.14 Feeling of incomplete bladder emptying R33.8 Other retention of urine R32. Unspecified urinary incontinence N39.41 Urge incontinence Q05. Spina Bifida G82.20 Paraplegia G82.50 Quadriplegia N39.0 History of UTIs

Other

Questions

Do you have allergies to products applied to the skin? Yes. If yes, please list. No

Allergies to Latex? Yes. If yes, please list. No

Quantity Underpads (Bed Liners) .

Quantity Adult Underware - Pull Ups (CASE) Small Medium Large X-Large

Quantity Incontinent Pad / Liners (box)

Quantity Drip Collector (box) Skin Barrier Ointment (each)

Quantity Leg Bag (each) Overnight Drainage Bag Small Medium Large

Quantity Adhesive Remover Wipes Skin Prep Wipes (box)

Quantity Tape (roll) Paper Cloth Waterproof 1” 2” 3”

Quantity Gloves Sterile Non-Sterile Vinyl Latex Small Medium Large

Quantity Wipes

Additional Comments

Shipping / Delivery

Nexus Best Method UPS Ground USPS Next Day Second Day Other ________________________

Ship to address Same as bill to address

Payment

Check Mastercard Visa American Express Discover

Name on Credit Card

Credit Card Number

Credt Card Expiration Date

Patient Info (or send face sheet) Physician

Name Marital status Sex N Nexus account-seq # DOB Age

Physician name CompanyPhone / Email Fax

Bill to address Phone / E-mailCity State Zip County

Physician address City State Zip

Emergency contact Emergency phoneRelationship to patient Emergency email

DEA # State license #NPI #

Primary Medical Insurance (New Patient Only) Secondary Medical Insurance (New Patient Only)

Plan Name Group Name

ID # Effective Date

Plan Name Group Name

ID # Effective Date

Relationship to member Member name Self (check and skip section) DOB Spouse Child Member ID #

Relationship to member Member name Self (check and skip section) DOB Spouse Child Member ID #

Primary Pharmacy Insurance (New Patient Only) Secondary Pharmacy Insurance (New Patient Only)

Plan Name Group #

BIN #

ID # PCN #

Relationship to insured Member Spouse Child Person Code

Plan Name Group #

BIN #

ID # PCN #

Relationship to insured Member Spouse Child Person Code

For O

ffice

Use

Only

: Rou

ting

OrderForm

Nexus Medical Equipment1352 Combermere Dr. Ste. ATroy, MI 48083Ph: 248.632.1700 Fax: 248-435-8602

Disposable Reuseable