What is the process for obtaining prescription‑required ostomy supplies for a patient, including insurance authorization for private, Medicare, or Medicaid coverage?

How to Obtain Ostomy Supplies for Your Patient

Ostomy supplies require a prescription from the physician, and the patient should be connected with a durable medical equipment (DME) supplier who will handle insurance authorization for private insurance, Medicare Part B, or Medicaid coverage. 1, 2

Prescription Requirements

• Write a prescription that includes the specific ostomy pouching system components (pouch type, skin barrier, accessories), quantities needed per month, and diagnosis code justifying medical necessity 1
• The prescription must specify whether the patient has an ileostomy, colostomy, or urostomy, as this affects the type of supplies covered 3, 4
• Include the patient's stoma characteristics (size, location, output volume) to justify the specific products prescribed 1

Insurance Authorization Process

Private Insurance

• Prior authorization is typically required before the DME supplier can ship supplies 5
• The DME supplier will submit the prescription and medical documentation to the insurance company on the patient's behalf 2
• Authorization usually takes 3-7 business days, so initiate this process before hospital discharge 2

Medicare Part B Coverage

• Medicare Part B covers ostomy supplies as durable medical equipment when medically necessary 1
• The patient must use a Medicare-approved DME supplier 2
• Medicare typically covers a 3-month supply at a time, with specific quantity limits per month based on the type of ostomy 1
• No prior authorization is required for standard supplies, but documentation of medical necessity must be available 2

Medicaid Coverage

• Medicaid coverage varies by state but generally covers medically necessary ostomy supplies 2
• Some states require prior authorization; the DME supplier will know state-specific requirements 2
• Quantity limits may be more restrictive than Medicare 1

Connecting Patient with DME Supplier

• Provide the patient with a list of at least 2-3 DME suppliers that accept their insurance before discharge 2
• The hospital's ostomy/wound care nurse or case manager typically maintains relationships with local DME suppliers and can facilitate this connection 1, 2
• Ensure the patient has enough supplies (typically 2-week supply minimum) to bridge the gap until the DME supplier delivers the first order 2

Essential Discharge Planning

• Document the exact pouching system the patient is using in the hospital (manufacturer, product numbers, sizes) so the DME supplier can provide identical supplies initially 1, 2
• Provide written instructions on how to order refills, including the DME supplier's phone number and the patient's account information 2
• Educate the patient that they will need to reorder supplies monthly or quarterly depending on their insurance plan 2

Common Pitfalls to Avoid

• Do not discharge the patient without confirming they have contacted a DME supplier and have adequate supplies at home 2
• Avoid generic prescriptions like "ostomy supplies as needed"—be specific about products and quantities to prevent authorization delays 1
• Do not assume the patient understands how to navigate insurance coverage; provide clear written instructions and contact information 2
• Ensure the prescription includes diagnosis codes (such as colorectal cancer, inflammatory bowel disease, diverticulitis) as insurance will deny claims without proper medical justification 1