Who bills, who services the patient, and what Synapse does with the order in the situations that come up most often.
Synapse Health is the supplier of record for the patients it manages, so the answer to ‘who bills for this?’ depends on the patient’s plan and on what is on the order. This article walks through the patient scenarios, the order scenarios, and the reconciliation deadlines that apply to each member transition phase.
For how payment actually reaches you once an order is complete, see the article on how to get paid.
Scenarios where a patient’s insurance or plan changes
These three scenarios cover an existing Synapse patient whose coverage or ordering situation changes.
| Billing scenario | Details / explanation |
|---|---|
| Existing Synapse patient switching insurance to fee-for-service (FFS) UnitedHealthcare plan | Synapse will continue as the DME provider of record and will bill the FFS plan. Subcontracted DME provider will continue to service rental/resupply related to rental under Synapse. |
| Existing Synapse patient new to Medicare OR non-contracted payor | Patient will be transitioned to previous DME provider. Transition needs to be initiated by Synapse and coordinated with DME provider. |
| Existing Synapse patient with a new order, outside of capitated agreement with UnitedHealthcare | Synapse will continue as the DME provider of record and will bill the FFS plan for any existing rental and related resupply. A new order for a product that is not related to existing services can be handled directly by the DME provider. |
Scenarios where an order includes a non-covered item
Synapse only provides Medicare-covered items. What happens to the order depends on whether the non-covered item is alone on the order or sits alongside a covered item.
| Order scenario | Details / explanation |
|---|---|
| Item outside patient / payer benefit scope | If an order includes a single item that is not covered under the patient’s or payer’s policy, it must be handled directly by the supplier. In such cases, Synapse will cancel the order. |
| Covered benefit accompanied by an excluded item | If an order includes both a covered item and a noncovered item, Synapse will accept, process, and pay the subcontractor for both covered and excluded items. |
| Upgrade to premium equipment (not covered by insurance) | Synapse only provides Medicare-covered items. If a patient opts for an upgrade or cross-sell item that is not covered, where they must pay out-of-pocket and cannot apply their DME benefit. These requests will be referred to the subcontractor through Fulfill as a fully patient pay referral order. |
Member transition phases and payment reconciliation deadlines
Submission and dispute deadlines differ by the phase in which a market transitioned to Synapse Health. Find the phase your market belongs to before you calculate a deadline.
| Member transition phase | Reconciliation |
|---|---|
| September 2024 – Georgia & North Carolina | Synapse Health will not process payments for backdated months, outside the 90-day timely filing period on orders sent greater than 90 days after delivery. Payment will begin using the earliest timely date of service. Payment disputes are submitted by completing the Payment Reconciliation Form. Disputes must be submitted within 30 days from the date of payment. |
| August 2025 – Virginia, Alabama, Tennessee, South Carolina | Patients, orders & required documentation must be submitted by 11/29/2025 (180 days). After 12/1/2025 Synapse Health will not process payments for backdated months, outside the 90-day timely filing period on orders sent to Synapse greater than 90 days after the date of service. Payment disputes for dates of services in 2025 can be requested up to 12/31/2025. |
| Future expansions | Patients, orders & required documentation are required 60 days from the start date of member transitions. Disputes must be submitted within 30 days from the date of payment. |
Submitting a claim that is past timely filing
If a claim is past timely filing, the subcontractor may submit documentation for consideration – for example proof that a payor recently recouped payment based on updated coordination of benefits indicating the patient was covered by another payor.
Where to get help with a billing scenario
If your situation does not match one of the scenarios above, or you are unsure which transition phase applies to your market, contact DME provider support before you submit the order.
