Form 4116-DME, ICF/IID Durable Medical Equipment Summary Sheet

Instructions for Opening a Form

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Effective Date: 8/2007


Updated: 7/2008


Providers must submit Form 4116-DME to HHSC to request reimbursement authorization.


Include at least two bids that include specifications from the durable medical equipment (DME) suppliers, or justification for not providing two bids, and proof of payment for DME (i.e., receipt from supplier, copy of check used for purchase or statement detailing amount paid with proof of payment for portion not paid for by Medicare).

  • Only the format on Form 4116-DME will be accepted. Different formats will be rejected and returned to the provider.
  • Form 4116-DME is to be used for multiple individuals for one calendar month.
  • List each DME item separately.
  • Use one set of forms for each month of claims. Do not include billings for multiple months on the same Form 4116-DME.
  • For each provider number (facility), submit one form for the total amount to be paid for each individual month. A form must be submitted for the total dollar amount of claims identified on the form.
  • Receipts that indicate payments have been made to the DME supplier must accompany Form 4116-DME. The receipts must match the dollar figure on Form 4116-DME and must clearly identify the individual for whom the DME was purchased.
  • To facilitate the payment process, organize and submit the billing claims information as follows:
    • Form 4116-DME(s),
    • individual receipt(s), and
    • bid specifications.
  • Failure to follow these instructions will result in Form 4116-DME being returned to the intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) provider.


All claims and documentation are mailed to:

ICF/IID Billing Specialist
Claims Management, Mail Code E-400
P.O. Box 149030
Austin, TX 78714-9030

For questions on how to complete Form 4116-DME, call the Provider Claims Services Help Desk at 512-438-2200, option 5.

Detailed Instructions

Facility Name — Enter the name of facility requesting payment.

Billing Month — Enter the current billing month. Use a separate Form 4116-DME for each month of billing.

Contract Number — Enter the nine-digit number that identifies the contract under which the individual is receiving ICF/IID services.

Client Name — Enter the last, first and middle initial for each client.

Client Medicaid No. — Enter the nine-digit Medicaid Identification number assigned to the individual.

DME Year Begin Date — Enter the DME year begin date that was initiated with the first purchase of DME. If an individual is discharged and re-enters the ICF/IID within the same DME year, the DME year remains unchanged. However, if the individual is discharged and remains discharged from the program until after the current DME year expires, a new DME year may be established. If an individual transfers from one ICF/IID program to another, the DME year remains the same.

DME Year Costs Year-to-Date — Enter the total cumulative cost of DME services previously billed during the current DME year.

Date Service Received — Enter the date the individual received the DME.

Receipt Date — Enter the receipt date if different from the service received date.

DME Item/Service Description — Enter a brief description of the item or service purchased for the individual.

5132X – Standing Boards
5135X – Gait Trainers
5179X – Travel Chairs
E0186 – Air Flotation or Air Pressure Mattress or Cushions
E0250 – Hospital Water Beds and Mattresses
E1130 – Wheelchairs
E1031 – Adaptive Strollers
E1340 – Refurbishing and Modifications of Wheelchairs
L3952 – Prosthetic/Orthotic Devices
E1902 – Communication Aid - Augmentive Devices
E1900 – Electronic Communication Device – Augmentive Devices

Dollars Spent — Enter the actual cost of the DME as reflected by the receipt.

Total Annual Cost Year-to-Date — Enter the total cost of DME services purchased during the current DME year. The total cost includes previous and current purchase costs.

DME Provider No. — Enter the Medicare-certified DME supplier's provider number assigned by Texas Medicaid and Healthcare Partnership (TMHP).

MED NEC – Check this box if a Note of Medical Necessity has been provided by the physician.

Bid – Check this box to indicate that the bid specification for the individual's DME is included with packet submitted for payment.

Receipt – Check this box to indicate that the receipt, indicating payment has been made to the DME supplier, is included with packet submitted for payment.

EOB – Check this box if an Explanation of Benefits letter has been received from Medicare (third-party insurance).

Contact Person — Enter the name of the person to be contacted if questions arise concerning the request for payment.

Area Code and Telephone No. — Enter the area code and telephone number of the contact person.