Jurisdiction B DME MAC Supplier Manual
Transcription
Jurisdiction B DME MAC Supplier Manual
Jurisdiction DME MAC Supplier Manual Jurisdiction B DME MAC Supplier Manual Foreword [MARCH 2008] J urisdiction B DME MAC Supplier Manual ABOUT THIS MANUAL The Jurisdiction B DME MAC Supplier Manual is designed to assist suppliers in claim submission of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) to the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC). National Government Services, Inc. will continue to advise suppliers and physicians filing DMEPOS claims the in Jurisdiction B geographical area of Medicare policy and procedure changes that are implemented by the Centers for Medicare & Medicaid Services (CMS). In addition to the Jurisdiction B DME MAC Supplier Manual, be sure to read the Jurisdiction B Connections, published on a quarterly basis, for more detailed information concerning Medicare program updates and changes. The Jurisdiction B Connections is available at www.NGSMedicare.com. Contact the Jurisdiction B DME MAC Customer Care Contact Center toll free at 866-590-6727, 8:30 a.m. to 5:30 p.m. Eastern Time (ET), Monday through Friday, for all Jurisdiction B states. The Interactive Voice Response (IVR) system is also available at 877-299-7900 from 6:00 a.m.–7:00 p.m. ET. ABOUT NATIONAL GOVERNMENT SERVICES Throughout the country, National Government Services, Inc. has efficient operational, financial, and human resources in place, positioning the organization as a national leader in the Medicare industry. National Government Services (with its corporate predecessors) maintains the following contracts: Medicare Part A Fiscal Intermediary for: California, Connecticut, Delaware, Hawaii, Illinois, Indiana, Kentucky, Maine, Massachusetts, Michigan, Nevada, New Hampshire, New York, Ohio, Vermont, Virginia, West Virginia, Wisconsin, and the U.S. Territories of American Samoa, Guam and Northern Mariana Islands. Medicare Part A Regional Home Health Intermediary for: Alaska, Arizona, California, Connecticut, Hawaii, Idaho, Maine, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New York, Oregon, Rhode Island, Vermont, Washington and the U.S. Territories of American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and U.S. Virgin Islands. Part B Carrier for: Indiana, Kentucky, New Jersey, and New York Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor for: Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin i Jurisdiction B DME MAC Supplier Manual Table of Contents [MARCH 2008] T able of Contents 1 2 General Information The Medicare Program 1 The Medicare Card 1 The Common Working File 2 Deductible and Coinsurance 3 The CMS Internet-Only Manuals 3 Enrollment Process Obtaining and Retaining Medicare DMEPOS Billing Privileges 1 Change of Information 5 Directory of Medicare Suppliers 5 Supplier Standards 6 Change of Ownership 9 Resources Available to Assist Suppliers with the Enrollment Process 3 4 10 Participation Program Enrollment 1 Benefits of Participation 2 Assignment of Claims 2 Medicare Secondary Payer Coordination of Benefits Contractor 1 Medicare’s Role 2 Medicare Secondary Payer Programs 3 Billing Requirements 9 Claim Liability Calculation 10 Medicare Secondary Payer Overpayments 11 Sample Jurisdiction B DME MAC MSP Voluntary Refund Form Sample Jurisdiction B DME MAC MSP Offset Request Form Sample Admission Questions to Ask Medicare Beneficiaries 1 15 Jurisdiction B DME MAC Supplier Manual Table of Contents [MARCH 2008] 5 6 7 8 Medicare Policy Information General Medical Policy Information 1 Current DMEPOS Medical Policies 7 Certificates of Medical Necessity/DME Information Forms Overview 1 DME Forms 1 External Infusion Pumps & Enteral/Parenteral Nutrition 2 CMN/DIF Completion Instructions 2 Cover Letters 5 Section C Example 5 Sample CMN Forms 6 HCPCS Codes Requiring a CMN or DIF 6 Documentation Orders 1 Certificates of Medical Necessity 4 Documentation in the Patient’s Medical Record 4 Proof of Delivery Requirements 5 Requests for Additional Information 7 Advance Determination of Medicare Coverage Eligible Items 1 Submitting ADMC Requests 1 ADMC Requirements 2 ADMC Determination 5 Sample ADMC Request Form 9 Advance Beneficiary Notice General Guidelines 1 Limitation on Liability 2 2 Jurisdiction B DME MAC Supplier Manual Table of Contents [MARCH 2008] Upgrades 3 Advance Beneficiary Notice Completion 4 Sample Form CMS-R-131-G Advance Beneficiary Notice 10 11 Claim Filing Jurisdiction Claim Filing Based on Beneficiary Address 1 Disposition of Incorrectly Filed Claims 1 Durable Medical Equipment Medicare Administrative Contractors 2 DME MAC Jurisdictions 3 Claim Submission Acceptable Claim Formats 1 Claim Filing Time Limits 1 Signature on File Requirements 3 Ordering Claim Forms 4 CMS-1500 Hints and Tips 5 New Revised CMS-1500 Form (Version 08-05) 6 Sample CMS-1500 Form (Version 08-05) CMS-1500 Form (Version 08-05) Field Descriptions and Instructions 12 9 Mailing Address 22 Resources 22 Electronic Data Interchange Electronic Media Claims 1 Administrative Simplification Compliance Act 2 Electronic Format 2 How to Become an Electronic Submitter 3 Testing Process and Requirements 4 Express Plus 5 Front-End Error Report 6 Claim Status Inquiry/Beneficiary Eligibility 7 Electronic Remittance Advice 7 Electronic Funds Transfer 8 Jurisdiction B DME MAC EDI Helpdesk 8 3 Jurisdiction B DME MAC Supplier Manual Table of Contents [MARCH 2008] 13 14 Password Reset Requests 9 E-Commerce Consultants 9 National Government Services Web Site 10 EDI List Serve 10 E-Commerce Connection 10 Level II HCPCS Codes and HCPCS Modifiers Level II HCPCS Codes 1 HCPCS Modifiers 3 The Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) 7 DMEPOS Payment Categories Inexpensive or Other Routinely Purchased DME 1 Items Requiring Frequent and Substantial Servicing 1 Customized Items 1 Other Prosthetic and Orthotic Devices 2 Transcutaneous Electrical Nerve Stimulators 2 Parenteral and Enteral Nutrition Pumps 3 Home Dialysis Supplies 3 Capped Rental Items 4 Oxygen and Oxygen Equipment 6 Repairs, Maintenance and Replacement 13 Sample Rent/Purchase Option for Power Wheelchairs Letter 15 Sample ESRD-382 Form 15 Pricing Fee Schedules 1 Reasonable Charges 2 Drug Pricing 4 Individual Consideration 5 Inherent Reasonableness 5 4 Jurisdiction B DME MAC Supplier Manual Table of Contents [MARCH 2008] 16 17 18 19 Medicare Benefit and Denial Categories Benefit Categories 1 Denial Categories 3 Prevention of Common Claim Submission Errors 6 Supplier Remittance Notice General Information 1 Tips for Reading the Remittance Notice 1 Sample Remittance Notice 3 Remittance Notice Key 4 Resources 6 Medicare Summary Notice Sample MSN 2 Summary of Numbered Fields on Sample MSN 4 Resources 5 Reopenings and Appeals Reopenings for Minor Errors and Omissions 1 Appeals 3 Sample Jurisdiction B DME MAC Request for Redetermination Form Sample Jurisdiction B DME MAC Reconsideration Request Form Sample Form CMS-1696 Appointment of Representative Sample Form CMS-20034 Request for Part B Medicare Hearing by an ALJ 20 Overpayments DME MAC Initiated Demand Letters 1 The Offset Process 1 Immediate Offset by Fax 2 Appealing a Refund 2 Supplier Voluntary Refunds 2 5 Jurisdiction B DME MAC Supplier Manual Table of Contents [MARCH 2008] Lost or Mutilated Checks 3 Change of Address 3 Sample Jurisdiction B DME MAC PCU Voluntary Refund Form Sample Jurisdiction B DME MAC PCU Offset Request Form 21 22 Customer Care Interactive Voice Response System 1 Customer Care Contact Center 1 Telephone Inquiries 2 Written Inquiries 4 Resources Jurisdiction B DME MAC Contact Information 1 Jurisdiction B DME MAC Forms Index 3 Acronyms 5 6 Jurisdiction B DME MAC Supplier Manual Chapter 1: General Information [MARCH 2008] 1 General Information THE MEDICARE PROGRAM The Medicare program is a federal health insurance program whose beneficiaries include persons 65 years of age or older, disabled persons, and persons with chronic renal disorders. It is governed by the Centers for Medicare & Medicaid Service (CMS) of the U.S. Department of Health and Human Services. The Social Security Administration (SSA) offices across the country take applications for Medicare and provide general information about the program. The SSA is also responsible for any changes or termination of a patient’s Medicare enrollment. The program was established by Congress in 1965 when it enacted Title XVIII of the Social Security Act, hereafter referred to as “the Act.” The Medicare program consists of two distinct parts. Part A—Hospital Insurance Hospital Insurance (Part A) helps pay for inpatient care in hospitals, critical access hospitals and skilled nursing facilities. It also covers hospice care and some home health care. Part B—Medical Insurance Medical Insurance (Part B) covers items and/or services that are medically necessary by a physician, outpatient hospital services, home health care, and a number of other medical services not covered by Part A benefits including durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Enrollment for Part B coverage is voluntary. Individuals pay a monthly premium which can be deducted from monthly Social Security benefits. Individuals must meet an annual deductible* each calendar year before Part B benefits are paid. * The Part B deductible for 2008 is $135 and is subject to change each year. By law, Medicare does not cover supplies or services received outside of the United States. The United States includes the 50 states, District of Columbia, Commonwealth of Puerto Rico, Virgin Islands, Guam, American Samoa and the territorial waters adjoining these land areas. Review the Claim Filing Jurisdiction chapter of the Jurisdiction B DME MAC Supplier Manual for details on the geographical locations included in Jurisdiction B. THE MEDICARE CARD All beneficiaries receive a health insurance card showing whether they have Hospital insurance (Part A), Medical insurance (Part B), or both, and the effective date(s) of coverage. When a husband and wife are both covered, each will have a separate card and Medicare Claim Number (i.e., Health Insurance Claim Number [HICN]). 1 Jurisdiction B DME MAC Supplier Manual Chapter 1: General Information [MARCH 2008] Sample Medicare card: Medicare HICN In order for Medicare claims to process correctly, the patient’s complete name, as it appears on the card, and the HICN should be correctly entered on all Medicare claims. To ensure accuracy, the supplier should view the actual card and record the information or make a photocopy for their records. Each patient’s health insurance card should be rechecked at least once a year since HIC numbers can change depending on the type of benefits a beneficiary is currently entitled to under the SSA. If the beneficiary insists the Medicare card is incorrect, the supplier should advise the beneficiary to contact their local servicing Social Security Field Office to obtain a new Medicare card. Information that does not match eligibility records will cause suspension or denial of claims. Note: The letters at the end of the beneficiary’s HIC # do not necessarily indicate the type of coverage they have. Example: 456-45-6456A does not mean the beneficiary has Part A only, or 456 46 6456B does not indicate that this beneficiary has elected Part B benefits. THE COMMON WORKING FILE The Common Working File (CWF) is the system used by the CMS to verify entitlement and correct utilization of benefits. The CWF houses the records of all claims processed for all beneficiaries assigned to that site. When a claim is processed, the CWF checks its records to verify eligibility, days used, deductible and coinsurance status and other utilization edits. The CWF contains information regarding the beneficiary’s date of birth, date of death (if applicable), health maintenance organization (HMO) and hospice elections and other information used to determine the correct utilization of benefits. When a contractor receives a claim, a query is sent to the CWF to verify the HICN and the name of the patient, as well as the appropriate utilization of benefits. Accurate reporting of the HICN is critical to the CWF. 2 Jurisdiction B DME MAC Supplier Manual Chapter 1: General Information [MARCH 2008] DEDUCTIBLE AND COINSURANCE Deductible Each calendar year the patient must satisfy a deductible* before Medicare Part B payments can be made. The Part B deductible is subject to change each year. The total Medicare allowed amount on a claim is reduced by the amount of any remaining deductible prior to payment. Charges that are denied, or that are noncovered, do not count toward the deductible. All individuals covered under Medicare are required to satisfy the full deductible amount regardless of when during the year their eligibility began. In other words, individuals who become eligible for Medicare in December are responsible for the full deductible amount. * The Part B deductible for 2008 is $135. Coinsurance For most services, Medicare pays 80 percent of the allowed amount for covered services after subtracting any remaining deductible. Medicare beneficiaries are responsible for the remaining 20 percent of the allowed amount (i.e., coinsurance payment) and any deductible subtracted on the claim. In some cases, a beneficiary’s supplemental insurance coverage will pay these amounts. On assigned claims, it is recommended the supplier only collect the 20 percent coinsurance from the beneficiary at the time of delivery. This will allow for the accurate calculation of deductible status by Medicare and prevent any refund to the beneficiary of over-collected deductible amounts. THE CMS INTERNET-ONLY MANUALS The CMS Internet-Only Manuals (IOMs), part of the CMS Online Manual System, is used by the various CMS program components, partners, contractors, and state survey agencies to administer CMS programs. They are the CMS’ program issuances, day-to-day operating instructions, policies, and procedures that are based on statutes, regulations, guidelines, models, and directives. The IOMs are also a good source of Medicare and Medicaid information for the general public. To view the IOMs, go to www.cms.hhs.gov/Manuals/IOM/list.asp. 3 Jurisdiction B DME MAC Supplier Manual Chapter 2: Enrollment Process [DECEMBER 2007] 2 Enrollment Process OBTAINING AND RETAINING MEDICARE DMEPOS BILLING PRIVILEGES Under durable medical equipment (DME) jurisdictional processing, every supplier of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) must obtain billing privileges from the National Supplier Clearinghouse (NSC). A supplier is an entity or individual, which provides, sells or rents DMEPOS to Medicare beneficiaries. The NSC is the organizational entity contracted by the Centers for Medicare & Medicaid Services (CMS) to issue Medicare billing privileges to suppliers of DMEPOS and to maintain a supplier file that contains information collected via the CMS-855S enrollment form. The NSC distributes enrollment supplier applications (Provider/Supplier Enrollment Application or CMS-855S form), verify the data, issue billing privileges to approved suppliers and maintain a national DMEPOS supplier file. The NSC must process supplier data and issue billing privileges before a supplier may start submitting claims to a durable medical equipment Medicare administrative contractor (DME MAC). The NSC will verify all information submitted. The supplier must complete the CMS-855S application and meet one of the following conditions if they plan to bill Medicare for DMEPOS: Enrolling in Medicare for the first time as a DMEPOS supplier Currently enrolled in Medicare as a DMEPOS supplier and need to report changes to their business, other than enrolling a new business location (e.g., they are adding, deleting or changing existing information under this Medicare supplier billing number) Currently enrolled in Medicare as a DMEPOS supplier but need to enroll a new business location. Note: This is to add a new location to an organization with a tax identification number already listed with the NSC (this differs from changing information on an already existing location). Note: 42 C.F.R. 424.57(b)(1) requires suppliers to enroll separate physical locations other than warehouses or repair facilities. Currently enrolled in Medicare as a DMEPOS supplier and have been asked to reenroll in order to verify or update their information (includes situations where the supplier has been asked to attest that their organization is still eligible to receive Medicare payments) Reactivating their Medicare DMEPOS supplier billing privileges (e.g., their Medicare supplier billing privileges were deactivated because of no billing activity and they wish to receive payment from Medicare for future claims) 1 Jurisdiction B DME MAC Supplier Manual Chapter 2: Enrollment Process [DECEMBER 2007] Voluntarily terminating their Medicare DMEPOS supplier billing privileges Instructions on how to obtain and complete the CMS-855S may be found under the Supplier Enrollment/Forms/CMS-855S Form section of the NSC Web site at www.PalmettoGBA.com/NSC. The supplier is accountable for the accuracy of the information on the CMS-855S form. Any deliberate misrepresentation or concealment of material information may subject the supplier to liability under civil and criminal laws. The NSC will contact a supplier if a CMS-855S form is incomplete or has inconsistent information. Further, all suppliers are subject to a site visit in order to determine compliance with the supplier standards. Suppliers found in noncompliance with the supplier standards are subject to denial or revocation of their NSC issued billing privileges. The denial/revocation notification outlines the appeals process available to suppliers, including instructions on requesting an appeal. According to the CMS Internet-Only Manual (IOM) Publication 100-8, Medicare Program Integrity Manual, Chapter 10, Section 6.2, a supplier that is denied enrollment in the Medicare program cannot submit a new enrollment application until the following has occurred: If the denial was not appealed, the provider or supplier may reapply after its appeal rights have lapsed. If the denial was appealed, the provider or supplier may reapply after it received notification the determination was upheld. Each DMEPOS supplier applying for Medicare billing privileges must disclose ownership on the CMS-855S form in accordance with Section 1124A of the Social Security Act and Section 4313 of the Balanced Budget Act of 1997, by including the following information: The names and social security numbers of the owners, managing employees, those with controlling interest of five percent or more, and/or authorized representatives/members of the board of directors (including nonprofit corporations) as well as any partnership regardless of the percentage of ownership. The names of all owners, managing employees and/or authorized representatives/members of the board of directors who have received penalties, been sanctioned, or excluded by the Medicare, Medicaid and/or other federal and state authorities or programs. The term managing employee is defined as any individual, including a general manager, business manager, or administrator, who exercises operational or managerial control over the DMEPOS supplier, or who conducts the day-to-day operations of the DMEPOS supplier. For Medicare enrollment purposes, “managing employee” also includes individuals who are not actual employees of the DMEPOS supplier but, either under contract or through some other arrangement, manage the day-to-day operations of the DMEPOS supplier. 2 Jurisdiction B DME MAC Supplier Manual Chapter 2: Enrollment Process [DECEMBER 2007] An authorized official must be an owner, general partner, chairman of the board, chief financial officer, chief executive officer, or president or must hold a position of similar status and authority within the supplier's organization. This individual must have the authorization to legally bind the organization to a contract. The authorized official has the authority to sign the initial CMS-855S application on behalf of the supplier and to notify the NSC of any change or that the billing privileges are no longer valid due to sale of the entity. Only the authorized official can add, change or delete delegated officials or sign off on the change of the authorized official. Adding delegated officials is an option and is not required. Delegated officials may either be a managing employee of the supplier, or hold a five percent direct ownership interest or partnership interest in the supplier. Managing employees include general managers, business managers, or administrators—individuals who exercise operational or managerial control over the supplier, or who conduct the day-to-day operations of the supplier. A delegated official must be an employee of the supplier, and proof, such as a W-2 form, may be requested. Delegated officials may not delegate their authority to any other individual. Once a delegated official has been designated, he/she may make any changes and/or updates to the provider status including enrolling additional locations, reenrolling the supplier, reactivating the supplier or adding new part-owners. Suppliers may have as many authorized and delegated officials as desired as long as the individual meets the respective definition. These officials are not location specific, but rather are supplier specific. For example, if a supplier has multiple locations under one tax id number, the authorized and delegated officials appointed will be the authorized signers for all locations. On May 1, 2006, CMS issued the revised CMS-855 Medicare enrollment applications. Listed below are changes and enhancements made specifically to the CMS-855S. DMEPOS suppliers should review and become familiar with this information. Requires the submission of the national provider identifier (NPI) and a copy of the NPI notification furnished by the National Plan and Provider Enumeration System (NPPES). Suppliers should provide their NPI where requested and submit a copy of the notification verifying the NPI. Suppliers unable to locate their NPI notification should contact the NPPES at 800-465-3203 or send an e-mail to [email protected]. Applying for the NPI is a process separate from Medicare enrollment. To obtain an NPI, the supplier may apply online at https://NPPES.cms.hhs.gov. For more information about NPI enumeration, go to www.cms.hhs.gov/NationalProvIdentStand. Note: Each enrolled supplier of DMEPOS that is a covered entity under Health Insurance Portability and Accountability Act (HIPAA) must designate each practice location (if they have more than one) as a subpart and ensure that each subpart obtains its own unique NPI. Federal regulations require that each location of a Medicare DMEPOS supplier have its own unique billing number. In order to comply with that regulation, each location must have its own unique NPI. 3 Jurisdiction B DME MAC Supplier Manual Chapter 2: Enrollment Process [DECEMBER 2007] In addition, the address listed on the NPI notification must match the address listed on the CMS-855S. CMS requires a copy of the notification to be submitted with all enrollment documentation, which includes initial applications, changes of information, reenrollments and reactivations. Requires suppliers to complete the Authorization Agreement for Electronic Funds Transfer (CMS-588). With regards to DMEPOS enrollment, suppliers should submit the CMS-588 electronic funds transfer (EFT) form when initially enrolling or submitting an application for an additional location. Suppliers must list the proper Medicare contractor and ensure the form has the original signature of the authorized or delegated official. Also, suppliers should submit a separate form for each Medicare contractor where it submits claims. Note: Suppliers completing a reenrollment package, who are not currently enrolled in the EFT program, should submit the completed CMS-588 form along with the required attachment verifying the bank account information. The NSC will then forward the form to the appropriate DME MAC for processing. Along with the completed form, suppliers must include one of the following verifying the account information: − Voided check − Deposit slip − Notification on bank letterhead verifying the account information The role of the NSC is to verify the form is complete, confirm the correct DME MAC has been indicated (based on the information the supplier has provided on the CMS-855S) and to ensure the agreement is signed properly. Once verified, the NSC will send the agreements to the appropriate DME MAC for processing. Again, suppliers should only submit the CMS-588 form to the NSC when submitting the CMS-855S for initial enrollment when enrolling an additional location or reenrolling and not currently enrolled in the EFT program. The NSC does not enroll suppliers into the EFT program. Any changes to EFT information should be submitted following existing procedures. A new section was added for suppliers to provide a specific address of where the NSC should mail their reenrollment packages. If a supplier would like to receive their reenrollment at an address other than the address where correspondences are received, the supplier should list this address in Section 2.A.3. This enhancement was made to provide all suppliers, especially those suppliers with multiple locations, a single address where they would like their reenrollment packages mailed. Requires suppliers to provide the name and phone number of the insurance underwriter. The NSC is required by CMS to verify coverage. Section 2.D requires suppliers to provide identifying information for both the insurance agent and the underwriter. Providing this information will assist in facilitating the verification process. On April 2, 2007, CMS issued a Final Rule on accreditation for DMEPOS suppliers. Because of the Final Rule, Section 2.F was added for suppliers to provide information concerning accreditation. 4 Jurisdiction B DME MAC Supplier Manual Chapter 2: Enrollment Process [DECEMBER 2007] Requires suppliers list the state(s) where items or services are being provided. Section 4 is where suppliers will indicate what jurisdiction the majority of claims will be submitted and list the individual states where items and services are provided. This information is being collected in order to ensure suppliers are properly licensed in the states where they provide Medicare-covered items to beneficiaries. CHANGE OF INFORMATION Any changes or updates to information provided on the CMS-855S form must be reported to the NSC within 30 days after such changes have taken place. Updated information should be submitted on the CMS-855S form. Failure to provide the updated information is grounds for denial or revocation of the Medicare supplier number. In order to receive timely information from the DME MAC, the NSC must have the supplier’s correct address. The NSC maintains the supplier’s correspondence address information and transmits this information to the DME MAC. All changes, including changes in address, must be reported to the NSC. Be sure to attach all location specific licenses to any Change of Information form that includes a change of physical location. This will be required before any changes can be made to the supplier file. This serves as notice to suppliers that they should apply for any new location-specific licenses from the specific licensing board (e.g., the Board of Pharmacy, business license offices, etc.) as quickly as possible to ensure compliance with supplier standard #1. Further instructions on how to complete a change of information for various reasons may be found in the Supplier Enrollment/Change of Information section of the NSC Web site at www.PalmettoGBA.com/NSC. All CMS-855S forms and changes to previously submitted information must be sent to: Regular Mail Address Overnight Mail Address National Supplier Clearinghouse AG-495 P.O. Box 100142 Columbia, South Carolina 29202-3142 National Supplier Clearinghouse AG-495 2300 Springdale Drive, Bldg 1 Camden, South Carolina 29020 DIRECTORY OF MEDICARE SUPPLIERS The CMS is responsible for producing a directory of all Medicare suppliers. This directory will not include physicians or ambulatory surgical centers that furnish supplies, except optometrists. The directory of Medicare suppliers can be found online at www.medicare.gov/Supplier/Home.asp. 5 Jurisdiction B DME MAC Supplier Manual Chapter 2: Enrollment Process [DECEMBER 2007] SUPPLIER STANDARDS Medicare regulations have defined standards a supplier must meet to receive and maintain billing privileges. These standards can be found in the Supplier Enrollment/Standards & Compliance/Supplier Standards section of the NSC Web site at www.PalmettoGBA.com/NSC. The Medicare DMEPOS supplier standards were finalized and became effective December 11, 2000. These standards are listed below. Source: Section 424.57 Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges. (A) Definitions As used in this Section, the following definitions apply: DMEPOS Stands for durable medical equipment, prosthetics, orthotics, and supplies. DMEPOS supplier An entity or individual, including a physician or a Part A provider, which sells or rents Part B covered items to Medicare beneficiaries and which meets the standards in paragraph (c) of this section. Medicare covered items means medical equipment and supplies as defined in Section 1834(j)(5) of the Social Security Act. (B) General Rule A DMEPOS supplier must meet the following conditions in order to be eligible to receive payment for a Medicare-covered item: 1) The supplier has submitted a completed application to CMS to furnish Medicare-covered items including required enrollment forms. (The supplier must enroll separate physical locations it uses to furnish Medicare-covered DMEPOS, with the exception of locations that it uses solely as warehouses or repair facilities.) 2) The item was furnished on or after the date CMS conveyed billing privileges to the supplier. 3) The CMS has not revoked or excluded the DMEPOS supplier’s privileges during the period which the item was furnished has not been revoked or excluded. 4) A supplier that furnishes a drug used as a Medicare-covered supply with durable medical equipment or prosthetic devices must be licensed by the state to dispense drugs (A supplier of drugs must bill and receive payment for the drug in its own name. A physician, who is enrolled as a DMEPOS supplier, may dispense, and bill for, drugs under this standard if authorized by the state as part of the physician's license.) 5) The supplier has furnished to CMS all information or documentation required to process the claim. 6 Jurisdiction B DME MAC Supplier Manual Chapter 2: Enrollment Process [DECEMBER 2007] (C) Application Certification Standards The supplier must meet and must certify in its application for billing privileges that it meets and will continue to meet the following standards: 1) Operates its business and furnishes Medicare-covered items in compliance with all applicable Federal and State licensure and regulatory requirements. 2) Has not made, or caused to be made, any false statement or misrepresentation of a material fact on its application for billing privileges. (The supplier must provide complete and accurate information in response to questions on its application for billing privileges. The supplier must report to CMS any changes in information supplied on the application within 30 days of the change.) 3) Must have the application for billing privileges signed by an individual whose signature binds a supplier. 4) Fills orders, fabricates, or fits items from its own inventory or by contracting with other companies for the purchase of items necessary to fill the order. If it does, it must provide, upon request, copies of contracts or other documentation showing compliance with this standard. A supplier may not contract with any entity that is currently excluded from the Medicare program, any state health care programs, or from any other Federal Government Executive Branch procurement or nonprocurement program or activity. 5) Advises beneficiaries that they may either rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental durable medical equipment, as defined in Section 414.220(a) of this subchapter. (The supplier must provide, upon request, documentation that it has provided beneficiaries with this information, in the form of copies of letters, logs or signed notices.) 6) Honors all warranties expressed and implied under applicable state law. A supplier must not charge the beneficiary or the Medicare program for the repair or replacement of Medicare-covered items or for services covered under warranty. This standard applies to all purchased and rented items, including capped rental items, as described in Section 414.229 of this subchapter. The supplier must provide, upon request, documentation that it has provided beneficiaries with information about Medicare-covered items covered under warranty, in the form of copies of letters, logs, or signed notices. 7) Maintains a physical facility on an appropriate site. The physical facility must contain space for storing business records including the supplier’s delivery, maintenance, and beneficiary communication records. For purposes of this standard, a post office box or commercial mailbox is not considered a physical facility. In the case of a multisite supplier, records may be maintained at a centralized location. 8) Permits CMS, or its agents to conduct on-site inspections to ascertain supplier compliance with the requirements of this section. The supplier location must be accessible during reasonable business hours to beneficiaries and to CMS, and must maintain a visible sign and posted hours of operation. 7 Jurisdiction B DME MAC Supplier Manual Chapter 2: Enrollment Process [DECEMBER 2007] 9) Maintains a primary business telephone listed under the name of the business locally or toll-free for beneficiaries. The supplier must furnish information to beneficiaries at the time of delivery of items on how the beneficiary can contact the supplier by telephone. The exclusive use of a beeper number, answering service, pager, facsimile machine, car phone, or an answering machine may not be used as the primary business telephone for purposes of this regulation. 10) Has a comprehensive liability insurance policy in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. In the case of a supplier that manufactures its own items, this insurance must also cover product liability and completed operations. Failure to maintain required insurance at all times will result in revocation of the supplier's billing privileges retroactive to the date the insurance lapsed. 11) Must agree not to contact a beneficiary by telephone when supplying a Medicare-covered item unless one of the following applies: (i) The individual has given written permission to the supplier to contact them by telephone concerning the furnishing of a Medicare-covered item that is to be rented or purchased. (ii) The supplier has furnished a Medicare-covered item to the individual and the supplier is contacting the individual to coordinate the delivery of the item. (iii) If the contact concerns the furnishing of a Medicare-covered item other than a covered item already furnished to the individual, the supplier has furnished at least one covered item to the individual during the 15-month period proceeding the date on which the supplier makes such contact. 12) Must be responsible for the delivery of Medicare covered items to beneficiaries and maintain proof of delivery. (The supplier must document that it or another qualified party has at an appropriate time, provided beneficiaries with necessary information and instructions on how to use Medicare covered items safely and effectively). 13) Must answer questions and respond to complaints a beneficiary has about the Medicare-covered item that was sold or rented. A supplier must refer beneficiaries with Medicare questions to the appropriate carrier. A supplier must maintain documentation of contacts with beneficiaries regarding complaints or questions. 14) Must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries. The item must function as required and intended after being repaired or replaced. 15) Must accept returns from beneficiaries of substandard (less than full quality for the particular item) or unsuitable items (i.e., inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries. 16) Must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item. 17) Must comply with the disclosure provisions in Section 420.206 of this subchapter. 8 Jurisdiction B DME MAC Supplier Manual Chapter 2: Enrollment Process [DECEMBER 2007] 18) Must not convey or reassign a supplier’s billing privileges. 19) Must have a complaint resolution protocol to address beneficiary complaints that relate to supplier standards in paragraph (c) of this section and keep written complaints, related correspondence and any notes of actions taken in response to written and oral complaints. Failure to maintain such information may be considered evidence that supplier standards have not been met. (This information must be kept at its physical facility and made available to CMS, upon request.) 20) Must maintain the following information on all written and oral beneficiary complaints, including telephone complaints, it receives: (i) Name, address, telephone number, and health insurance claim number of the beneficiary. (ii) A summary of the complaint; the date it was received; the name of the person receiving the complaint, and a summary of actions taken to resolve the complaint. (iii) If an investigation was not conducted, the name of the person making the decision and the reason for the decision. 21) Provides to CMS, upon request, any information required by the Medicare statute and implementing regulations. (D) Failure to Meet Standards The CMS will revoke a supplier’s billing privileges if it is found not to meet the standards in paragraphs (b) and (c) of this section. (The revocation is effective 15 days after the entity is sent notice of the revocation, as specified in Section 405.874 of this subchapter.) (E) Renewal of Billing Privileges A supplier must renew its application for billing privileges every three years after the billing privileges are first granted. Each supplier must complete a new application for billing privileges three years after its last renewal of privileges. The NSC will notify suppliers via mail when a new renewal application is due. CHANGE OF OWNERSHIP When there is a change of ownership, new billing privileges must be issued unless the new owners assume all liabilities and the tax identification number of the existing supplier. Otherwise, the new owner may not use the existing supplier’s billing privileges (supplier standard #18). The new owner must submit form CMS-855S to the NSC within thirty (30) days of the change of ownership, along with a bill of sale, articles of incorporation filed with the state and any other documents that show the exact nature of the transaction. 9 Jurisdiction B DME MAC Supplier Manual Chapter 2: Enrollment Process [DECEMBER 2007] If there is a change in the tax identification number, the outgoing owner must notify the NSC by completing the CMS-855S as a “Voluntary Termination of Billing Number.” The request to voluntarily terminate the supplier’s billing privileges must be submitted on the CMS-855S. Per Chapter 10, Section 7 of the CMS IOM Publication 100-08, Medicare Program Integrity Manual, all changes must be reported on the CMS-855S. The old billing privileges will be inactivated. If the NSC determines the new owners have met all requirements, the new privileges will be effective from the date of the change of ownership. Claims for items furnished between the date of the change of ownership and the issuance of the new privileges may be submitted to the DME MAC once the supplier has received the new privileges. Further information about change in ownership, including instructions on how to submit a voluntary termination, may be found in the Supplier Enrollment/Standards & Compliance/Change of Information section of the NSC Web site at www.PalmettoGBA.com/NSC. RESOURCES AVAILABLE TO ASSIST SUPPLIERS WITH THE ENROLLMENT PROCESS The NSC Web Site www.PalmettoGBA.com/NSC Helpful hints for completing the CMS-855S Numerous Frequently Asked Questions (FAQs) regarding the enrollment process The NSC Top Ten—the top ten reoccurring issues that delay processing Information regarding the NSC site visit process Licensure information A checklist to ensure the CMS-855S was completed properly and that all required documentation has been provided The NSC Customer Service Line 866-238-9652 NSC analysts are available Monday through Friday from 9:00 a.m. until 5:00 p.m. Eastern Time (ET) to answer questions regarding the enrollment process. If the supplier has questions regarding supplier specific information, please be sure the caller is listed on the supplier file. NSC analysts will not be able to give supplier specific information to someone who is not listed on the supplier file. The NSC also has a voice mailbox available to Spanish suppliers who do not speak English. 10 Jurisdiction B DME MAC Supplier Manual Chapter 2: Enrollment Process [DECEMBER 2007] NSC E-Mail Address [email protected] If preferred, suppliers can e-mail their questions to this address. Questions received will be answered within a reasonable time frame. The NSC suggests suppliers do not submit protected health care information via e-mail. NSC Interactive Voice Response Unit The NSC Interactive Voice Response (IVR) Unit allows suppliers to obtain: General information regarding the enrollment process Information on the appeals process Status of a new application, reenrollment, reactivation or change of information Instructions on how to obtain a CMS-855S Contact information for the NSC, durable medical equipment regional carrier/DME MACs and CMS The IVR is available 24-hours a day, seven days a week (except for routine system maintenance) and can be accessed by calling the NSC Customer Service line at 866-238-9652. 11 Jurisdiction B DME MAC Supplier Manual Chapter 3: Participation Program [DECEMBER 2007] 3 Participation Program The Medicare participation program involves a voluntary agreement between a supplier and Medicare. Under the agreement, the supplier agrees to accept assignment for all services rendered to Medicare beneficiaries and to accept the Medicare allowed amount as the total charge for any covered item. Any Medicare-enrolled supplier may choose to participate in the program. Participation is not automatic; the assignment of a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier number does not enroll a supplier in the program. A separate participation agreement must be filed with the National Supplier Clearinghouse (NSC). Once a supplier is enrolled in the program, the agreement applies to locations enrolled under the same tax identification number. Participation is not location specific. This is true whether the supplier is an individual, partnership or corporation. ENROLLMENT The participation enrollment form is available on the NSC Web site at www.PalmettoGBA.com/NSC. Suppliers may also obtain an enrollment form by calling the NSC toll free at 866-238–9652, or by writing to: National Supplier Clearinghouse Palmetto GBA—AG-495 P.O. Box 100142 Columbia, South Carolina 29202-3142 If preferred, suppliers can e-mail their questions to [email protected]. Questions received will be answered within a reasonable time frame. The NSC suggests that suppliers refrain from submitting protected healthcare information via e-mail. The Centers for Medicare & Medicaid Services (CMS) offers an open enrollment period each year when suppliers may enroll in the program or provide notice of the termination of their participation agreement. The open enrollment period usually takes place mid-November to the end of December. The NSC notifies suppliers of the specific dates for the enrollment period each year. In order to terminate a participation agreement, a supplier must notify the NSC in writing during the enrollment period. The written notice must be postmarked before the end of the enrollment period and have the original signature of the authorized official. The termination will be effective January 1 of the following year. The NSC will acknowledge receipt of a request, which has been completed appropriately and has the proper original signature, to enroll or to terminate enrollment in the participation program. Suppliers who do not receive an acknowledgement within a reasonable time should contact the NSC. 1 Jurisdiction B DME MAC Supplier Manual Chapter 3: Participation Program [DECEMBER 2007] BENEFITS OF PARTICIPATION By agreeing to accept assignment on all claims, a participating provider receives certain advantages. By accepting assignment, a supplier: requests direct payment from Medicare for covered items; accepts the Medicare allowed amount as the full charge for the item or service; and has the right to appeal claim determination by the durable medical equipment Medicare administrative contractor (DME MAC). Medicare also advertises the participation status of providers to beneficiaries by providing a directory of participating providers to senior citizens groups and, upon request, to individual Medicare beneficiaries. Medicare provides for the automatic crossover of claims to Medigap insurers for participating providers. In other words, when a participating supplier provides the appropriate information on a claim for a beneficiary who has a Medigap insurance policy, Medicare will transfer the claim information to the Medigap insurer after processing, reducing paperwork for the supplier. Refer to the Paper Claim Form Completion chapter of this manual for CMS-1500 claim form completion instructions to ensure automatic crossover. ASSIGNMENT OF CLAIMS It should be noted that the terms participating and nonparticipating refer to suppliers. The terms assigned and nonassigned refer to claims. By accepting assignment on a claim a supplier agrees to accept Medicare’s allowed amount as the full charge for the items or services provided. This means that for covered services, the supplier may collect only the deductible and remaining coinsurance amounts from the beneficiary. A claim for an assigned item is considered paid in full when the DME MACs allowed amount is paid. On an assigned claim that was denied because the beneficiary did not meet Medicare’s medical necessity criteria, the beneficiary may be held financially responsible for Medicare’s allowed amount if an acceptable Advance Beneficiary Notice (ABN) was obtained. Refer to Chapter 9, Advanced Beneficiary Notice, for detailed information regarding ABN requirements. For noncovered items, the beneficiary may be held financially responsible for the supplier’s entire charge regardless of whether the claim is filed assigned or nonassigned. Assignment for Nonparticipating Suppliers Suppliers who have not enrolled in the participation program (i.e., nonparticipating suppliers) may accept assignment on a claim-by-claim basis. On a nonassigned claim that was denied because the beneficiary did not meet Medicare’s medical necessity criteria, the beneficiary may be held financially responsible for the supplier’s entire charge if an acceptable ABN was obtained prior to rendering the services. A nonparticipating supplier may not file assigned claims for some items and nonassigned claims for other items when they were provided to the same beneficiary on the same date. 2 Jurisdiction B DME MAC Supplier Manual Chapter 3: Participation Program [DECEMBER 2007] Once a claim has been filed as assigned, it may not be changed to nonassigned without the consent of both the beneficiary and the supplier. The notice to rescind must be received by the DME MAC prior to payment determination. Assignment Violation When an assignment violation is noted by the DME MAC through the review of a claim or through a beneficiary complaint, the DME MAC will educate the supplier on the terms of the assignment agreement. The supplier may be required to return a refund and provide a corrected statement to the beneficiary. Where there are repeated violations of the assignment agreement, the DME MAC may suspend further payment to the supplier on assigned claims as directed by the CMS. For payable claims, payment will be made directly to the beneficiary. The beneficiary will be advised that the supplier has not complied with the requirements for receiving payment from Medicare. 3 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] 4 Coordination of Benefits and Medicare Secondary Payer COORDINATION OF BENEFITS CONTRACTOR Reference: Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-05, Medicare Secondary Payer Manual, Chapter 4, Coordination of Benefits Contractor (COBC) Requirements, www.cms.hhs.gov/manuals/downloads/msp105c04.pdf The Coordination of Benefits Contractor (COBC) consolidates the activities that support the collection, management and reporting of other insurance coverage for Medicare beneficiaries. The COBC is primarily an information gathering entity whose purpose is to identify the health benefits available to a Medicare beneficiary and to coordinate the payment process to prevent mistaken payment of Medicare benefits. The COBC is dependent upon various sources to collect this information, including beneficiaries, providers, suppliers and Medicare contractors. The COBC is virtually responsible for all initial Medicare Secondary Payer (MSP) development activities formerly performed by contractors. COBC responsibilities include: Ensuring the accuracy and timeliness of updates to the Common Working File (CWF) MSP auxiliary file Developing claims to determine the existence or validity of MSP for Medicare beneficiaries. Handling all MSP related inquiries, including those seeking general MSP information, but not those related to specific claims or recoveries. These inquiries (verbal and written) can come from any source, including but not limited to beneficiaries, attorneys/beneficiary representatives, employers, insurers, providers, suppliers and contractors. Assigning new Medigap claim-based Coordination of Benefits Agreement (COBA) identifiers to Medigap insurers On October 1, 2007, the COBC assumed responsibility for the Medigap claim-based crossover, which will be driven by information that participating providers enter on the incoming claim. Participating providers that are permitted under the Administrative Simplification Compliance Act (ASCA) to bill Medicare on paper should include the newly assigned five-digit COBA Medigap claimbased ID within Item 9-D of the CMS-1500 claim form. In accordance with Public Law 104-191 and 45 Code of Federal Regulations (CFR) 160, the COBC will only transmit claim to Medigap claim-based crossover recipient in the Health Insurance Portability and Accountability Act (HIPAA) American National Standards Institute (ANSI) X12-N 837 professional (version 4010A1) coordination of benefits (COB) claim format, or in the National Council for Prescription Drug Program (NCPDP) version 5.1 batch standard 1.1 format. 1 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] Note: Providers may reference a weekly updated listing of the newly assigned COBA Medigap claim-based IDs for Medicare billing purposes at the following Web site: www.cms.hhs.gov/COBAgreement/Downloads/Medigap%20Claimbased%20COBA%20IDs%20for%20Billing%20Purpose.pdf The COBC does not process claims, nor does it handle any mistaken payment recoveries or claims specific inquiries. The Medicare intermediaries and carriers are responsible for processing claims submitted for primary or secondary payment. Refer to the information below to determine whom to contact to resolve specific MSP-related questions. Contact the COBC to: report employment changes or any other insurance coverage information; report a liability, auto/no-fault or Workers’ Compensation case; ask general MSP questions/concerns; and ask questions regarding MSP letters and questionnaires. Contact your local Medicare intermediary or carrier to: answer questions regarding Medicare claim or service denials and adjustments; answer questions concerning how to bill for payment; process claims for primary or secondary payment; and accept the return of inappropriate Medicare payment. The COBC Customer Service number is 800-999-1118. Hours of operation are 8:00 a.m.–8:00 p.m. Eastern Time, Monday–Friday, except holidays. Direct general written inquiries to: Medicare—Coordination of Benefits P.O. Box 5041 New York, New York 10274-5041 MEDICARE’S ROLE Reference: CMS IOM Publication 100-05, Medicare Secondary Payer Manual, www.cms.hhs.gov/Manuals/IOM/list.asp. Since the Medicare program’s inception, Congress has enacted a number of laws that have made Medicare a secondary payer to other insurance in certain situations. The role of MSP in particular situations is similar to the coordination of benefits clauses in private health insurance policies. Ordinarily, Medicare should be viewed as a secondary payer when a beneficiary can reasonably be expected to receive medical benefits through one or more of the following situations: 2 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] Group health plan (GHP) meeting MSP provisions for Age, Disability, or End-Stage Renal Disease (ESRD) Accidents with available no-fault (nonliability, med-pay) or liability insurance Workers’ Compensation Federal Black Lung Program Veterans Administration Please note that Medigap, Medicaid and TRICARE are not among the programs primary to Medicare. Upon initial contact with the patient, providers/suppliers determine if there are any other payers that may be primary to Medicare. A sample MSP questionnaire is included at the end of this chapter. Suppliers are encouraged to use this questionnaire or a similar form of their own to help identify payers that may be primary to Medicare. Once a supplier has identified the primary payer, the supplier should bill that payer first. Medicare should not be billed until the supplier has received notice of payment or rejection by the primary insurer. Once the notice is received, the supplier must include the primary payer information on the Medicare claim (see the Billing Requirements section of this chapter for instructions). When Medicare is the secondary payer, certain information is needed to determine Medicare liability. Medicare must know how much the primary insurer allowed and how much the primary insurer paid. Many Medicare patients have other insurance that is primary to Medicare. Suppliers who fail to identify payers that are primary to Medicare may have their claims denied. Early detection of an MSP situation and proper billing will result in improved claims flow. MEDICARE SECONDARY PAYER PROGRAMS Reference: CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 2, MSP Provisions, www.cms.hhs.gov/manuals/downloads/msp105c02.pdf During the registration process, suppliers should screen their patients to determine if there are other payers that may be primary to Medicare. The following information provides details about the various MSP programs. Employer Group Health Plans Medicare is secondary payer for some beneficiaries who are enrolled in an employer group health plan (EGHP). Medicare defines an EGHP as any health plan that is offered to employees and their families by an employer of 20 or more full-time and/or part-time employees. This definition includes a multiemployer group health plan (GHP) that has at least one employer with 20 or more employees. The durable medical equipment Medicare administrative contractor (DME MAC) assumes, in the absence of contrary evidence, that EGHPs meet the 20 employee test. If the beneficiary has appealed or is protesting an EGHP denial, conditional primary benefits may be paid for any reason other than the following: 3 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] 1) The EGHP offers only secondary coverage of services covered by Medicare, or 2) The EGHP denied the claim because the time limit for filing the claim with Medicare expired, or 3) The EGHP denied the claim because the time limit for filing the claim with the EGHP expired (whether appealed or not) Working Aged In 1982, Congress created the MSP category known as Working Aged. The current rules regarding the Working Aged have been in effect since May 1, 1986. For services rendered on or after this date, Medicare will be secondary for those people age 65 and over who are covered under an EGHP. The EGHP must be through the current employment of the beneficiary or his/her spouse, and the employer must have a minimum of 20 employees. There are no longer any age ceilings for the beneficiary, as long as he/she is at least 65. Similarly, a working spouse of the beneficiary may be any age. Example: Mr. Patrick is 71 years old and retired. Mrs. Patrick is employed at a real estate office that employs 24 people, and carries group insurance on both her and Mr. Patrick. Medicare is secondary. The employer insurance should be billed first for all durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) items. Individuals with End-Stage Renal Disease Medicare is secondary to benefits payable under a GHP for individuals of any age who are entitled to Medicare benefits due to end-stage renal disease (ESRD). The GHP may be through a current or former employer of the beneficiary or through coverage of another family member who covers the beneficiary on their group health plan. (Exception: A retirement plan which has become secondary payer to Medicare does not have to revert to being primary payer.) Medicare is secondary payer for a period of 30 months. This 30-month period (the ESRD coordination period) begins with the first month of Medicare eligibility. After the 30-month period has been completed, Medicare will be primary regardless of other available GHPs. For patients undertaking hemodialysis, there is a three-month waiting period before they are eligible for Medicare benefits. Patients who undertake peritoneal dialysis may waive the three-month waiting period. In the case of a kidney transplant, Medicare coverage can begin the month an individual is admitted to an approved hospital for a kidney transplant or procedures preliminary to a transplant if the transplant takes place in that month or within the two following months. If the transplant is delayed more than two months after the individual is admitted to the hospital, Medicare coverage will begin two months before the month the actual transplant takes place, or if earlier, the first day of the third month after the monthly maintenance dialysis began. Example 1: An individual begins routine hemodialysis in April 2005. He/she would have a threemonth waiting period (April, May and June) and would then be eligible for Medicare benefits on July 1, 2005. His/her 30-month ESRD coordination period would be from July 2005 through December 2007. 4 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] Example 2: An individual begins routine peritoneal dialysis in April 2005. He/she could waive the three-month waiting period and Medicare eligibility would begin immediately. His/her 30-month ESRD coordination period would be from April 2005 through September 2007. Note: In the examples above, if the individual was covered under a GHP through their own or another family member’s current or former employment with an employer of any size, the GHP would be the primary payer throughout the 30-month ESRD coordination period. For beneficiaries entitled to Medicare solely on the basis of ESRD, Medicare coverage ends 12 months after the month they no longer require maintenance dialysis treatments or 36 months after the month of a successful kidney transplant. If the transplant fails during or after that 36-month period and the beneficiary resumes maintenance dialysis or receives another transplant, Medicare coverage will continue or be reinstated immediately without any waiting period. If an individual has more than one period of entitlement based solely upon ESRD, a coordination period is determined for each period of entitlement. In the case where a kidney transplant fails and the individual requires dialysis after the 36-month period of Medicare entitlement, the 30-month coordination period begins with the month in which renal dialysis begins, not three months after the month dialysis is reinstated. This is because a second waiting period is not required for re-entitlement to Medicare for situations involving kidney transplant failure. However in the case where a kidney transplant fails and the individual requires dialysis before the 36-month period of entitlement ends, there is no break in Medicare entitlement and thus no new coordination period. Individuals with Disability Medicare is secondary payer for a beneficiary entitled to Medicare due to a disability other than ESRD who also meets the following criteria: 1) He/she is under age 65, and 2) Covered under a large group health plan (LGHP) due to either his/her own employment or the employment of a family member with an employer of 100 or more employees. (Note: Employers must comply with the disability provisions when they have met the criteria of having 100 or more full and/or part-time employees for at least 50 percent of their business year.) MSP status for a disabled Medicare beneficiary is determined by the existence of LGHP coverage based upon the beneficiary’s or a family member’s current employment status (per the Omnibus Budget Reconciliation Act [OBRA’93] effective August 10, 1993). An individual has current employment status with an employer if: 1) The individual is actively working as an employee, or 2) The individual is the employer (including self-employed persons), or 3) The individual is associated with the employer in a business relationship Dual Entitlement When a beneficiary’s entitlement to Medicare can be based upon more than one provision, Dual Entitlement exists. Under prior MSP law, Medicare became the primary payer when a Medicare 5 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] beneficiary became dually entitled to Medicare, e.g., disability and ESRD or age and ESRD. This changed with the passage of OBRA 1993. It is no longer mandatory for Medicare to be the primary payer in cases of dual entitlement. Section 13561(c) of OBRA 1993 (effective August 10, 1993) provided that Medicare will remain the secondary payer throughout a coordination period. Even if the beneficiary becomes entitled to Medicare based on disability or age before the ESRD coordination period ends, Medicare will remain secondary payer. Additionally, a coordination period applies when Medicare is secondary due to the Age or Disability provision and the beneficiary then becomes entitled due to ESRD. If the beneficiary loses entitlement due to ESRD but retains Medicare coverage due to age or disability, then the MSP Age or Disability provisions will apply. Note: A beneficiary is not dually entitled to Medicare by age and disability. When a disabled beneficiary reaches age 65, he/she becomes entitled to Medicare by age and is no longer covered under the Medicare Disability provision. If the beneficiary or their spouse is working, the Working Aged provision would apply. Accidents Medicare may revert to secondary payer for covered items when payment may reasonably be expected to be made under a no-fault insurance (i.e., nonliability, med-pay), or a liability insurance. Note: Medicare will be secondary payer regarding claims involving the conditions related to the accident. Medicare would retain its normal payment status on other claims. Additional Documentation When filing a claim for conditions which result from an accident, additional documentation is necessary, such as: The specific location of the accident A statement of whether or not the beneficiary feels someone else is liable The name and address of the liable party The name, address and policy number of the liable party’s insurance (this may be information for the beneficiary’s automobile insurance company if the beneficiary was involved in and responsible for an automobile accident) The names and addresses of any attorneys involved No-fault Insurance No-fault (or nonliability) insurance may include motor vehicle medical coverage, premises medical coverage, homeowner’s medical coverage or no-fault insurance. The supplier must pursue billing with a no-fault insurance company before it may bill Medicare. The supplier and the beneficiary are responsible for taking whatever action is necessary to obtain any payment that can reasonably be expected under no-fault insurance. Medicare does not pay until the beneficiary has exhausted his/her remedies under no-fault insurance. Medicare does not pay for services that would have been covered by the nonliability no-fault insurance if the beneficiary had filed a proper claim with those insurers. An exception is when the beneficiary, because of a physical or mental incapacity, failed to meet a claim filing requirement stipulated by the policy. 6 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] Note: If the no-fault insurance pays the beneficiary directly, the supplier must seek payment of those funds from the beneficiary and should not bill Medicare for those amounts. Liability Insurance Liability insurance (including a self-insured plan) provides payment based upon legal liability for injury or illness or damage to property or person. It may include automobile liability, uninsured motorist, underinsured motorist, homeowner’s liability, malpractice, product liability, and general casualty insurances. For purposes of billing Medicare, liability involvement is determined by the beneficiary statement as to whether or not he/she feels someone else is responsible for the accident/incident. If the beneficiary feels that someone else is responsible for the accident (not the claim), the supplier must also identify and pursue the liability insurance company before billing Medicare. The liability insurance must be pursued for the first 120 days. If the supplier receives a denial notice from the insurance company before 120 days have passed, or the 120 days have passed without resolution, they may bill Medicare conditionally. Example 1 (No-fault): A Medicare beneficiary falls at their neighbor’s home. They are not holding the neighbor responsible for the fall. However, the neighbor has no-fault (medical payments) coverage under their homeowner’s policy. The supplier would need to bill the homeowner’s policy for all claims related to this accident. The beneficiary does not have a choice in whether or not this policy is billed. Example 2 (No-fault): A Medicare beneficiary is involved in an automobile accident. They are not holding anyone else responsible for the accident. However, they have no-fault (medical payments) coverage under their automobile policy. The supplier would need to bill the beneficiary’s automobile policy for all claims related to this accident. Example 3 (Liability): A Medicare beneficiary falls in a grocery store. The grocery store does not carry no-fault (premises medical) insurance. However, the beneficiary is holding the grocery store responsible for the accident. The supplier would need to bill the grocery store’s liability insurance for all claims related to this accident. Note: If the injury resulted from an automobile accident and there is indication of primary coverage under an EGHP, the supplier bills the automobile medical or no-fault insurer or employer plan before requesting conditional Medicare payments. Workers’ Compensation Medicare payment may not be made if payment can reasonably be expected to be made under a Workers’ Compensation (WC) plan including plans provided under the Federal Employee’s Compensation Act and the U.S. Longshoremen’s and Harbor Workers’ Compensation Act. The beneficiary’s WC carrier should be billed first for all DMEPOS items related to the injury while at work. Conditional Medicare Benefits Conditional Medicare benefits may be paid while a WC claim is being contested. The beneficiary’s WC carrier must be pursued for the first 120 days. If the supplier receives a denial from the insurance company before 120 days or the 120 days have passed without resolution, the supplier may file the claim with Medicare conditionally. Frequently, there is a long delay between the occurrence of an 7 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] injury or illness and the decision by the state WC agency. A denial of Medicare benefits pending the outcome of the appeal would mean individuals might be required to advance their own funds to pay for expenses which would eventually be borne by either Medicare or WC. To avoid imposing hardship on Medicare beneficiaries, conditional Medicare payments may be made pending a final decision on the WC claim. Note: Medicare will not make conditional payments if a WC Medicare Set-Aside has been approved by CMS. Federal Black Lung Program Some Medicare beneficiaries are entitled to receive medical benefits under the Federal Black Lung Program when DMEPOS items are provided for a condition attributable to lung diseases or conditions caused by mining. The Department of Labor (DOL) administers the Federal Black Lung Program. If the supplier is aware that the beneficiary is entitled to benefits under this program, the DOL should be billed first for all DMEPOS items related to a black lung diagnosis. Mail claims to: Federal Black Lung Program CSC Correspondence Unit P.O. Box 740 Lanham, Maryland 20706 Medicare will continue to be primary payer for services not related to Black Lung disease. Suppliers identify the diagnosis, signs, or symptoms that caused the services to be rendered. Medicare secondary benefits may be available for services related to Black Lung disease. A copy of DOL’s benefits explanation must accompany a claim to Medicare for secondary payment. For a complete list of the diagnoses and conditions, as well as the items covered under the Federal Black Lung Program, please refer to the National Government Services Web site at www.adminastar.com/Providers/MSP/Programs/files/MedA_BlackLung.pdf, or submit a request in writing to: Freedom of Information P.O. Box 50454 Indianapolis, Indiana 46250-0454 Veterans Administration Veterans who are entitled to Medicare may choose which program will be responsible for payment of DMEPOS covered by both programs. Submit claims for which the veteran elects Medicare coverage to Medicare in the normal manner. A denial from the Veterans Administration (VA) is not needed prior to submitting a claim to Medicare. Claims cannot be submitted to both programs for the same dates and items. If a veteran elects Medicare coverage, a claim should not be submitted to VA for any portion of that claim. If a veteran elects VA coverage, a claim should not be submitted to Medicare for any portion of that claim. 8 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] Medicare and VA perform periodic computer data matches to identify duplicate payments. When duplicate payments are found, Medicare will pursue recovery of its payment and will request information for potential referral to the Internal Revenue Service or the Office of the Inspector General. Submit DMEPOS claims to VA in situations such as: 1) Outpatient medical services were authorized by VA in advance. (Note: A VA Fee-Basis Identification (ID) Card is not considered by Medicare to be an authorization. The veteran retains his/her right to elect VA or Medicare coverage.) 2) Care is not authorized by VA in advance; the veteran is eligible for payment for care as unauthorized service; the veteran chooses to submit a claim to VA for unauthorized services rather than utilizing Medicare benefits. Submit DMEPOS claims to Medicare in situations such as: 1) A veteran is eligible for Medicare benefits and hospital care is not authorized by VA in advance or within 72-hours of admission. 2) A veteran is eligible for Medicare benefits, has a VA Fee-Basis ID Card and elects Medicare coverage over VA. 3) A veteran is eligible for Medicare benefits and has no prior authorization from VA for care—unless the veteran is eligible for payment for care as an unauthorized service—and the veteran chooses to submit a claim to VA for unauthorized services rather than utilizing Medicare benefits. 4) A veteran is eligible for Medicare benefits and the VA has authorized payment for only a part of the hospital treatment period. CMS MSP Questionnaire CMS has created a questionnaire that contains questions that can be used to ask Medicare beneficiaries upon each inpatient and outpatient admission. The questionnaire is located in the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, at www.cms.hhs.gov/manuals/downloads/msp105c03.pdf A sample of the CMS MSP Questionnaire is located at the end of this chapter. Suppliers are encouraged to use the CMS MSP Questionnaire to screen for payers primary to Medicare. Note: Suppliers should begin using the CMS MSP questionnaire effective September 11, 2006. BILLING REQUIREMENTS Medicare Secondary Payer claims must be filed electronically unless an Administrative Simplification Compliance Act (ASCA) exception is met. Suppliers submitting MSP claims electronically must include the primary payer paid amount, approved amount, and allowed amount from the EOB in the 2320.AMT segment. Suppliers should contact their software vendor to determine how the 2320.AMT segment corresponds to their software program. Note: Suppliers that qualify for an ASCA exception, and are therefore submitting their claims hardcopy, must attach the EOB to the CMS-1500 claim form. 9 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] Medicare Secondary Claim Filing Tips A claim should be submitted to the primary insurer first. An Explanation of Benefits (EOB) or payment determination from the primary insurer must accompany each paper claim submitted to Medicare. Suppliers submitting MSP claims electronically must include the primary payer paid amount, approved amount, and allowed amount from the EOB in the 2320.AMT segment. If Medicare is secondary to a GHP, Items 11 and 11a–11c of the CMS-1500 claim form must be completed. If the claim is due to an accident, Items 10a–10c of the CMS-1500 claim form should be completed. Do not enter the primary insurer’s payment amount in Item 29 of the CMS-1500. Complete this field only if payment is received from the beneficiary. Submit the total charge, not the difference between your usual charge and the primary insurer's payment (i.e., coinsurance payment). The total charge should not be reduced to reflect the Medicare or primary insurer’s allowed amounts. Refer to the patient responsibility (PT RESP) field on the Medicare remittance notice to determine how much to bill the beneficiary. The coinsurance (COINS) and deductible (DEDUCT) fields are calculated based on the Medicare primary payment and do not apply to a secondary claim. CLAIM LIABILITY CALCULATION When Medicare receives a claim as the secondary payer, Medicare’s liability is the lower amount derived from three calculations. The first calculation determines how much Medicare would pay without regard to any primary insurer. The second calculation subtracts the primary insurer’s payment from the higher of the Medicare allowance or primary insurer’s allowance. Example 1: Assigned Claim Submitted Charge = $500 Primary Insurer’s Allowance = $500 Primary Insurer’s Payment = $000 Medicare Allowance = $380 This example assumes the $131 Medicare deductible had not been met. This example also assumes the primary insurer applied $500 to their deductible. Medicare Liability Without Regard to Other Insurance: $380 – 131 = 229 × 80% = $199.20 Medicare Liability Considering Other Insurer’s Payment: $500 – 0 = $500 Solution: Medicare would pay $199.20. The combined primary insurer’s payment and Medicare payment equals $199.20. Since this is an assigned claim, the beneficiary may be billed for $176.80, the $131.00 Medicare deductible and $45.80 of coinsurance. The provider will then have received $380. 10 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] Example 2: Assigned Claim Submitted Charge = $500 Primary Insurer’s Allowance = $500 Primary Insurer’s Payment = $320 Medicare Allowance = $380 This example assumes the $131 Medicare deductible has been met. Medicare Liability Without Regard to Other Insurance: $380 × 80% = $304 Medicare Liability Considering Other Insurer’s Payment: $500 – 320 = $180 Solution: Medicare would pay $180. The combined primary insurer’s payment and Medicare payment equals $500, thus no balance is due from the patient. The claim is paid in full. Example 3: Assigned Claim Submitted Charge = $500 Primary Insurer’s Allowance = $400 Primary Insurer’s Payment = $000 Medicare Allowance = $380 This example assumes the $131 Medicare deductible had been met. This example also assumes the primary insurer applied $400 to their deductible. Medicare Liability Without Regard to Other Insurance: $380 × 80% = $304 Medicare Liability Considering Other Insurer’s Payment: $400 – 0 = $400 Solution: Medicare would pay $304. The combined primary insurer’s payment and Medicare payment equals $304. Since this is an assigned claim, the beneficiary may be billed for $76, the Medicare coinsurance amount. The provider will then have received $380. MEDICARE SECONDARY PAYER OVERPAYMENTS If a provider, physician or supplier receives an overpayment that is a result of Medicare paying primary on a claim when the beneficiary has primary insurance coverage through another insurer, the provider, physician or supplier must refund Medicare’s overpayment. There are two methods suppliers may use to return Medicare’s overpayment in an MSP situation. The supplier may complete an MSP Voluntary Refund form and mail it, along with a copy of the primary payer’s Explanation of Benefits (EOB) and a check for the amount that is owed Medicare, to our office. Or, the supplier may complete an MSP Offset by Fax Request form and fax it, along with a copy of the primary payer’s EOB to our office. When an offset is requested, Medicare will calculate the amount of the overpayment based upon the information provided by the supplier and recoup the overpayment amount from a future 11 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] supplier payment. Calculating Medicare’s portion of a claim payment in MSP situations can be complicated. For this reason, suppliers may prefer to use the MSP offset by fax process. Note: If a supplier receives money from a liability insurer after having billed Medicare, the supplier may retain only the amount of any unpaid deductible, coinsurance and noncovered items and must return the balance of the liability payment to the liability insurer, the attorney or the Medicare beneficiary. Refund Forms The following pages include the approved MSP-related refund forms. Suppliers should use these forms only if an MSP-related voluntary refund needs to be submitted or if they need to request an offset by fax. The Jurisdiction B DME MAC MSP Voluntary Refund Form is located on the National Government Services Web site at www.adminastar.com/Providers/DMERC/Forms/files/MSP%20Voluntary%20Refund%20Form.pdf. The Jurisdiction B DME MAC MSP Offset Request Form is located on the National Government Services Web site at www.adminastar.com/Providers/DMERC/Forms/files/MSP%20Offset%20Request%20Form.pdf. These forms are also located on the National Government Services Web site at www.NGSMedicare.com: Select Select Select Select AdminaStar Federal Jurisdiction B DME MAC MSP MSP Forms 12 Jurisdiction B DME MAC MSP Voluntary Refund Form Shall Be Completed By Medicare Contractor Date: _______________________________________ Contractor Deposit Control #: ___________________________________________________ Date of Deposit: ______________________________ Contractor Contact Name: _____________________________________________________ Phone #:___________________________________________ Contractor Fax: _________________________________________________________ Contractor Address: __________________________________________________________________________________________________________ Shall Be Completed By Provider/Physician/Supplier, Or Other Entity Please complete and forward to your Medicare contractor. This form, or a similar document containing the following information, should accompany every unsolicited/voluntary refund so that receipt of check is properly recorded and applied. Physician/Supplier or Other Entity Name: ______________________________________________________________________________________ Address: ____________________________________________________________________________________________________________________ Provider/Physician/Supplier #: _________________________ Tax Id #: ____________________________________________________________ Contact Person: __________________________________________________ Phone #: _________________________________________________ Amount of Check $: __________________________ Check #: _________________________ Check Date: ______________________________ Refund Information For each claim, provide the following: Patient Name: _______________________________________________________ HIC #:_______________________________________________ Medicare Claim Number: _____________________________________________ Claim Amount Refunded $: ___________________________ Reason Code for Claim Adjustment: ___________________________________ (Reason Codes are listed below. Use one reason per claim.) (Please list all claim numbers involved. Attach separate sheet, if necessary) Note: If Specific Patient/HIC/Claim #/Claim Amount data not available for all claims due to Statistical Sampling, please indicate methodology and formula used to determine amount and reason for overpayment: _______________________________________________________________ ____________________________________________________________________________________________________________________________ Note: If specific patient/HIC/Claim # information is not provided, no appeal rights can be afforded with respect to this refund. Providers/physicians/suppliers, and other entities who are submitting a refund under the OIG’s Self‐Disclosure Protocol are not afforded appeal rights as stated in the signed agreement presented by the OIG. For Institutional Facilities Only: Cost Report Year(s) _________________________________ (If multiple cost report years are involved, provide a breakdown by amount and corresponding cost report year.) For OIG Reporting Requirements Do you have a Corporate Integrity Agreement with OIG? Are you a participant in the OIG Self‐Disclosure Protocol? Reason Codes Yes Yes No No Billing/Clerical: MSP/Other Payer Involvement: 01 – Corrected Date of Service 07 – MSP Group Health Plan Insurance 02 – Duplicate 08 – MSP No Fault Insurance 03 – Corrected CPT Code 09 – MSP Liability Insurance 04 – Not Our Patient(s) 10 – MSP, Worker’s Comp. (including Black Lung) 05 – Mod. Add/Remove 11 – Veterans Administration 06 – Billed in Error Mail Completed Form To: National Government Services, Inc. MSP Jurisdiction B DM E MAC Indiana Lockbox 660065 Indianapolis, Indiana 46266‐0065 National Government Services, Inc. Page: 1 of 1 MSP IN 042 02/07 Miscellaneous: 12 – Insufficient Doc 13 – Patient Enroll HMO 14 – Svcs. Not Rendered 15 – Medical Necessity 16 – Other‐Be Specific Jurisdiction B DME MAC MSP Offset Request Form Instructions This form should be used to initiate a request for immediate offset of an overpayment. There are two types of overpayments: (1) Demanded (i.e., Medicare identified), and (2) Voluntary (i.e., provider identified). Please fill out the appropriate section in its entirety and fax the completed form to 317‐841‐4480. Type of Refund Medicare identified—Section I (demand letter has been received) Provider identified—Section II (no letter has been received) I. Complete This Section for Medicare Identified Refunds Date of Request:_________________________ Amount of Overpayment $: _______________________ Claim Control Number: __________________ Accounts Receivable (AR) Number: ________________ Notes: • All of the above information can be found on the Medicare demand letter. • Please make sure you attach a copy of the first page of the original demand letter. II. Complete This Section for Provider Identified Refunds Date of Service: ___________________________ Beneficiary HIC #: ______________________________ Claim Control Number: ____________________ Amount of Overpayment $: ______________________ Specific Reason for Refund: _________________________________________________________________ Notes: • All of the information in the section above is required to ensure proper processing. • Please make sure you attach a completed copy of the Voluntary Refund Form for each request. This form can be found on the National Government Services, Inc. Web site (www.NGSMedicare.com). • A demand letter will be generated once this request has been fulfilled. You may disregard that letter. Provider Information (Required) Name: ____________________________________________ Provider #: _____________________________ Address: _____________________________________ City, State, Zip: _____________________________ Contact Name: _____________________________________ Phone #: _____________________________ Signature of Requestor: _____________________________________________________________________ National Government Services, Inc. Page: 1 of 1 MSP IN 040 02/07 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] SAMPLE ADMISSION QUESTIONS TO ASK MEDICARE BENEFICIARIES Revision 53, Issued June 9, 2006, Effective September 11, 2006, Implementation September 11, 2006. The following sample questionnaire contains questions that can be used to ask Medicare beneficiaries upon each inpatient and outpatient admission. Providers may use this as a guide to help identify other payers that may be primary to Medicare. This questionnaire is a model of the type of questions that may be asked to help identify MSP situations. Suppliers that choose to use this questionnaire should note that it was developed to be used in sequence. Instructions are listed after the questions to facilitate transition between questions. The instructions will direct the patient to the next appropriate question to determine MSP situations. Part I 1) Are you receiving Black Lung (BL) benefits? ______ Yes; Date benefits began (MM/DD/CCYY): __________________________________________ BL is primary payer only for claims related to BL. ______ No. 2) Are the services to be paid by a government research program? ______ Yes. Government research program will pay primary benefits for these services ______ No. 3) Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for your care at this facility? ______ Yes. DVA is primary for these services. ______ No. 4) Was the illness/injury due to a work-related accident/condition? ______ Yes; Date of injury/illness (MM/DD/CCYY):__________________________________________ Name and address of Workers’ Compensation (WC) plan:_____________________________________ ___________________________________________________________________________________ Policy or identification number: __________________________________________________________ Name and address of your employer: _____________________________________________________ ___________________________________________________________________________________ WC is primary payer only for claims for work-related injuries or illness, go to Part III. ______ No. Go to Part II. Part II 1) Was illness/injury due to a nonwork-related accident? ______ Yes; Date of accident (MM/DD/CCYY): ____________________________________________ ______ No. Go to Part III 15 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] 2) Is no-fault insurance available? (No-fault insurance is insurance that pays for health care services resulting from injury to you or damage to your property regardless of who is at fault for causing the accident.) ______ Yes. Name and address of no-fault insurer(s) and no-fault insurance policy owner: ____________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Insurance claim number(s): ____________________________________________________________ ______ No. 3) Is liability insurance available? (Liability insurance is insurance that protects against claims based on negligence, inappropriate action or inaction, which results in injury to someone or damage to property.) ______ Yes. Name and address of liability insurer(s) and responsible party: ________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Insurance claim number(s): ____________________________________________________________ ______ No. No-fault insurer is primary payer only for those services related to the accident. Liability insurance is primary payer only for those services related to the liability settlement, judgment, or award. Go to part III. Part III 1) Are you entitled to Medicare based on: ______ Age. Go to Part IV ______ Disability. Go to Part V ______ ESRD. Go to Part VI Please note that both “Age” and “ESRD” OR “Disability” and “ESRD” may be selected simultaneously. An individual cannot be entitled to Medicare based on “Age” and “Disability” simultaneously. Please complete ALL “PARTS” associated with the patient’s selections. Part IV—Age 1) Are you currently employed? ______ Yes. Name and address of your employer: _____________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ______ No. If applicable, date of retirement: (MM/DD/CCYY):_________________________________ ______ No. Never employed. 2) Do you have a spouse who is currently employed? ______ Yes. 16 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] Name and address of your spouse’s employer: _____________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ______ No. If applicable, date of retirement (MM/DD/CCYY): _________________________________ ______ No. Never employed. If the patient answered “No” to both questions 1 and 2, Medicare is primary unless the patient answered “Yes” to questions in Part I or II. Do not proceed further. 3) Do you have group health plan (GHP) coverage based on your own, or a spouse’s current employment? ______ Yes, both. ______ Yes, self. ______ Yes, spouse. ______ No. Stop. Medicare is primary payer unless the patient answered yes to the questions in Part I or II. 4) If you have GHP coverage based on your own current employment, does your employer that sponsors or contributes to the GHP employ 20 or more employees? ______ Yes. GHP is primary. Obtain the following information. Name and address of GHP: _____________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Policy identification number (this number is sometimes referred to as the health insurance benefit package number): ____________________________________________________________________ Group identification number: ____________________________________________________________ Membership number (prior to the Health Insurance Portability and Accountability Act (HIPAA), this number was frequently the individual’s Social Security Number (SSN); it is the unique identifier assigned to the policyholder/patient):_____________________________________________________ Name of policyholder/named insured:_____________________________________________________ Relationship to patient: ________________________________________________________________ ______ No. 5) If you have GHP coverage based on your spouse’s current employment, does your spouse’s employer that sponsors or contributes to the GHP, employ 20 or more employees? ______ Yes. GHP is primary. Obtain the following information. Name and address of GHP: _____________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Policy identification number (this number is sometimes referred to as the health insurance benefit package number): ____________________________________________________________________ Group identification number: ____________________________________________________________ Membership number (prior to the HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient): _______________________________________ Name of policyholder/named insured:_____________________________________________________ 17 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] Relationship to patient: ________________________________________________________________ ______ No. If the patient answered “no” to both questions 4 and 5, Medicare is primary unless the patient answered “yes” to questions in part I or II. Part V—Disability 1) Are you currently employed? ______ Yes. Name and address of your employer: _____________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ______ No. If applicable, date of retirement (MM/DD/CCYY): _________________________________ ______ No. Never employed. 2) Do you have a spouse who currently employed? ______ Yes. Name and address of your spouse’s employer: _____________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ______ No. If applicable, date of retirement (MM/DD/CCYY): _________________________________ ______ No. Never employed. 3) Do you have GHP coverage based on your own, or a spouse’s current employment? ______ Yes, both. ______ Yes, self. ______ Yes, spouse. ______ No. 4) Are you covered under the GHP of a family member other than your spouse? ______ Yes. Name and address of your family member’s employer: _______________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ______ No. If the patient answered “no” to questions 1, 2, 3 and 4, stop. Medicare is primary unless the patient answered “yes” to questions in part I or 11. 5) If you have GHP coverage based on your own current employment, does your employer that sponsors or contributes to the GHP employ 100 or more employees? ______ Yes. GHP is primary. Obtain the following information. Name and address of GHP: _____________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 18 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] Policy identification number (this number is sometimes referred to as the health insurance benefit package number): ____________________________________________________________________ Group identification number: ____________________________________________________________ Membership number (prior HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient): _____________________________________________ Name of policyholder/named insured:_____________________________________________________ Relationship to patient: ________________________________________________________________ ______ No. 6) If you have GHP coverage based on your spouse’s current employment, does your spouse’s current employer that sponsors or contributes to the GHP employ 100 or more employees? ______ Yes. GHP is primary. Obtain the following information. Name and address of GHP: _____________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Policy identification number (this number is sometimes referred to as the health insurance benefit package number): ____________________________________________________________________ Group identification number: ____________________________________________________________ Membership number (prior HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient): _____________________________________________ Name of policyholder/named insured:_____________________________________________________ Relationship to patient: ________________________________________________________________ ______ No. 7) If you have GHP coverage based on a family member’s current employment, does your family member’s employer that sponsors or contributes to the GHP, employ 100 or more employees? ______ Yes. GHP is primary. Obtain the following information. Name and address of GHP: _____________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Policy identification number (this number is sometimes referred to as the health insurance benefit package number): ____________________________________________________________________ Group identification number: ____________________________________________________________ Membership number (prior HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient): _____________________________________________ Name of policyholder/named insured:_____________________________________________________ Relationship to patient: ________________________________________________________________ ______ No. If the patient answered “no” to questions 5, 6, and 7, Medicare is primary unless the patient answered “yes” to questions in part I or II. Part VI—ESRD 1) Do you have GHP coverage? ______ Yes. 19 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] If applicable, your GHP information: Name and address of GHP: _____________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Policy identification number (this number is sometimes referred to as the health insurance benefit package number): ____________________________________________________________________ Group identification number: ____________________________________________________________ Membership number (prior to HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient): _____________________________________________ Name of policyholder/named insured:_____________________________________________________ Relationship to patient: ________________________________________________________________ Name and address of employer, if any, from which you receive GHP coverage: ___________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ If applicable, your spouse’s GHP information: Name and address of GHP: _____________________________________________________________ ___________________________________________________________________________________ Policy identification number (this number is sometimes referred to as the health insurance benefit package number): ____________________________________________________________________ Group identification number: ____________________________________________________________ Membership number (prior to HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient): _____________________________________________ Name of policyholder/named insured:_____________________________________________________ Relationship to patient: ________________________________________________________________ Name and address of employer, if any, from which your spouse receives GHP coverage: ___________ ___________________________________________________________________________________ ___________________________________________________________________________________ If applicable, your family members GHP information: ________________________________________ Name and address of GHP: _____________________________________________________________ ___________________________________________________________________________________ Policy identification number (this number is sometimes referred to as the health insurance benefit package number): ____________________________________________________________________ Group identification number: ____________________________________________________________ Membership number (prior to HIPAA, this number was frequently the individual’s SSN; it is the unique identifier assigned to the policyholder/patient): _____________________________________________ Name of policyholder/named insured:_____________________________________________________ Relationship to patient: ________________________________________________________________ Name and address of employer, if any, from which your family receives GHP coverage: ____________ ___________________________________________________________________________________ ___________________________________________________________________________________ ______ No. Stop. Medicare is primary. 2) Have you received a kidney transplant? ______ Yes. Date of transplant (MM/DD/CCYY): ____________________________________________ ______ No. 20 Jurisdiction B DME MAC Supplier Manual Chapter 4: Coordination of Benefits and Medicare Secondary Payer [DECEMBER 2007] 3) Have you received maintenance dialysis treatments? ______ Yes. Date dialysis began (MM/DD/CCYY):___________________________________________ If you participated in a self-dialysis training program, provide date training started (CCYY/MM/DD): ___________________________________________________________________________________ ______ No. 4) Are you within the 30-month coordination period that starts MM/DD/CCYY? (The 30-month coordination period starts the first day of the month an individual is eligible for Medicare [even if not yet enrolled in Medicare] because of kidney failure—usually the fourth month of dialysis. If the individual is participating in a self-dialysis training program or has a kidney transplant during the three-month waiting period, the 30-month coordination period starts with the first day of the month of dialysis or kidney transplant.) ______ Yes. ______ No. Stop. Medicare is primary. 5) Are you entitled to Medicare on the basis of either ESRD and age or ESRD and disability? ______ Yes. ______ No. 6) Was your initial entitlement to Medicare (including simultaneous or dual entitlement) based on ESRD? ______ Yes. Stop. GHP continues to pay primary during the 30-month coordination period. ______ No. Initial entitlement based on age or disability. 7) Does the working aged or disability MSP provision apply (i.e., is the GHP already primary based on age or disability entitlement? ______ Yes. Stop. GHP continues to pay primary during the 30-month coordination period. ______ No. Medicare continues to pay primary. If no MSP data are found in the Common Working File (CWF) for the beneficiary, the provider still asks the types of questions above and provides any MSP information on the bill using the proper uniform billing codes. This information will then be used to update CWF through the billing process. 21 Jurisdiction B DME MAC Supplier Manual Chapter 5: Medical Policy Information [MARCH 2008] 5 Medical Policy Information GENERAL MEDICAL POLICY INFORMATION Medical policies are a combination of national and regional decisions. The Centers for Medicare & Medicaid Services (CMS) defines national policy in the CMS Internet Only Manual (IOM) Publication 100-03, Medicare National Coverage Determinations Manual, and the CMS IOM Publication 100-08, Medicare Program Integrity Manual. The durable medical equipment Medicare administrative contractor (DME MAC) is required to follow national policy where it exists. However, when there is no national policy on a subject, the DME MAC has the authority and responsibility to establish regional policy. A local coverage determination (LCD), as established by Section 522 of the Benefits, Improvements & Protection Act (BIPA) of 2000, is a decision by a fiscal intermediary or carrier on whether to cover a particular service on a fiscal intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary). The Final Rule establishing LCDs was published in the Federal Register on November 7, 2003. Medical policies are published as two related documents: the LCD and a policy article. The major sections of the LCD are: Indications and Limitations of Coverage and/or Medical Necessity—This section defines coverage criteria based upon a determination of whether an item is reasonable and necessary. It includes information from National Coverage Determinations (NCDs) when applicable. When an item does not meet these criteria, it will be denied as “not medically necessary.” HCPCS Codes and Modifiers ICD-9 Codes and Diagnoses That Support Medical Necessity Documentation Requirements Revision History The major sections of the Policy Article are: Nonmedical Necessity Coverage and Payment Policy—This section identifies situations in which an item does not meet the statutory definition of a benefit category (e.g., durable medical equipment, prosthetic devices, etc.) or when it doesn’t meet other requirements specified in Regulations. It also identifies situations in which an item is statutorily excluded from coverage for reasons other than medical necessity. In these situations, the policies will continue to identify the denial as “noncovered.” This section may also include statements defining when an item will be denied as “not separately payable” or situations in which claim processing for the item is not within the Jurisdiction B DME MAC geographical area. Coding Guidelines 1 Jurisdiction B DME MAC Supplier Manual Chapter 5: Medical Policy Information [MARCH 2008] Note: The term Policy Article will have a very specific meaning and will be used in the title of the article to define the document that is related to the LCD. The LCD and Policy Article taken together will be referred to as the “medical policy.” The Policy Article will be part of the same document and will immediately follow the LCD in the medical policy. In the CMS database (http://cms.hhs.gov/mcd/indexes.asp), the Policy Article can be accessed both as an attachment to the LCD and as a separate article in the Articles section of the database. Medical Policy Development DME MAC medical policies are administrative and educational tools designed to inform suppliers and medical professionals about Medicare coverage requirements and to assist suppliers in submitting correct claims for payment. The development of medical policies is a collaborative effort led by the medical directors of the four DME MACs. The intent of the policy development process is to provide the opportunity for input from the supplier and medical community, to enhance the understanding of the policy by those individuals, and to assure that the final policy is consistent with sound medical practice. The initial stage of the process is the development of a draft policy. This is based on a review of the medical literature and the contractor’s understanding of medical practice relating to the item. The medical directors seek input from various individuals and groups during the drafting phase of policy development. Drafts of new medical policies or revised policies that propose more restrictive medical necessity coverage criteria are sent for comment to a wide spectrum of national and regional organizations representing manufacturers, suppliers, physicians and other healthcare professionals. These draft medical policies can be found on the National Government Services Web site at www.adminastar.com/Providers/DMERC/MedicalPolicy/MedicalPolicy.cfm. At least 45 days are allowed for comments to draft policies. Since there is no fixed schedule for the release of draft DME MAC policies, suppliers and other interested individuals should check the National Government Services Web site periodically for new information. The DME MAC encourages written comments to the draft policies. Commenters that disagree with any aspects of the policy should offer specific alternative wording and support their suggestions with references from the published medical literature. After the close of the comment period, the DME MAC medical directors review all of the comments received and revise the medical policy as appropriate. The medical directors summarize the comments and give a response to each indicating whether they agree or disagree with the suggestion. If they do not agree, they give reasons for the decision. This comment and response document is posted on the DME MAC’s Web site when the final policy is published. Per the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.1.4, the DME MACs shall ensure that the LCDs are developed and revised in accordance with CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.1.4. 2 Jurisdiction B DME MAC Supplier Manual Chapter 5: Medical Policy Information [MARCH 2008] CMS requires that the recommended LCDs developed by the DME MACs be identical for each jurisdiction to ensure uniformity for DMEPOS suppliers that operate nationally. The DME MACs shall maintain the LCD record. The LCD record shall consist of any document or material that the DME MACs considered during the development of the new or revised LCD, including, but not limited to, the following: 1) Any medical evidence considered on or before the date the LCD was recommended to the DME MACs for adoption, including, but not limited to, the following: Scientific articles Technology assessments Clinical guidelines Documentation from the Food and Drug Administration (FDA) regarding safety and efficacy of a drug or device with the exception of proprietary data and privileged information Statements from clinical experts, medical textbooks, claims data or other indication of medical standard of practice 2) Comment and response documents (a summary of all comments received by the DME MACs concerning the recommended LCD); this applies only to new LCDs or revised LCDs that were sent for comment. The DME MAC shall publish the adopted LCD by way of the Medicare Coverage Database (MCD). The DME MACs shall provide an Internet link on their contractor Web site to the MCD to provide access to the adopted LCD. Note: Final medical policies are published on the National Government Services Web site at www.adminastar.com/Providers/DMERC/MedicalPolicy/MedicalPolicy.cfm. Local Coverage Determination Reconsideration Process The LCD Reconsideration Process is a mechanism by which interested parties can request a revision of an LCD. In order to be considered a valid request, the following requirements must be met: Requestor must be qualified Subject must be appropriate Information submitted must be adequate Process for submission must be followed Any request for LCD reconsideration that, in the judgment of the DME MAC, does not meet these requirements is invalid. Requestor The DME MAC will consider all LCD reconsideration requests from: Beneficiaries residing in their jurisdiction, or Suppliers doing business in their jurisdiction 3 Jurisdiction B DME MAC Supplier Manual Chapter 5: Medical Policy Information [MARCH 2008] The DME MAC may consider LCD reconsideration requests from any other interested party doing business in their jurisdiction. Subject The LCD Reconsideration Process is available only for final LCDs. The whole LCD or any part of the LCD may be reconsidered. Requests are not accepted for other documents including: National Coverage Decisions (NCD) Coverage provisions in interpretive manuals—such as the CMS Internet Only Manual (IOM) Draft LCDs Retired LCDs Individual claim determinations Bulletins, articles, training materials Any instance in which no LCD exists, i.e., requests for development of an LCD If modification of the LCD would conflict with an NCD, the request is not valid. Refer to the NCD reconsideration process at http://www.cms.hhs.gov/DeterminationProcess/. Information to be Submitted The request must identify the language that the requestor wants added to or deleted from an LCD. Requests must include a justification supported by new evidence, which may materially affect the LCD’s content or basis. When articles or textbooks are cited, copies of the published documents must be included. The level of evidence required for LCD reconsideration is the same as that required for new/revised LCD development. As described in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, LCDs are to be based on the strongest evidence available. In order of preference, LCDs are based on: Published authoritative evidence derived from definitive randomized clinical trials or other definitive studies General acceptance by the medical community (standard of practice), as supported by sound medical evidence based on: − Scientific data or research studies published in peer-reviewed medical journals, or − Consensus of expert medical opinion (i.e., recognized authorities in the field), or − Medical opinion from medical associations or other health care experts Acceptance by individual health care providers, or even a limited group of health care providers, normally does not indicate general acceptance by the medical community. Testimonials indicating such limited acceptance, and limited case studies distributed by sponsors with financial interest in the outcome, are not sufficient evidence of general acceptance by the medical community. The broad range of available evidence will be considered and its quality will be evaluated before a conclusion is reached. 4 Jurisdiction B DME MAC Supplier Manual Chapter 5: Medical Policy Information [MARCH 2008] Submission Process In order to be valid, the request for LCD reconsideration must be in writing and must include the name and mailing address of the requestor. Inclusion of a telephone number and/or email address is optional. If the requestor is a supplier, the supplier number must be included. If the requestor is neither a beneficiary nor a supplier, the requestor must identify the nature of their business and who they represent (if applicable). Requests may be submitted by mail, e-mail or fax to: National Government Services, Inc. Attn: Medical Policy P.O. Box 6036 Indianapolis, Indiana 46206-6036 [email protected] -OrFax: 317-841-4600 DME MAC Response Within 30 days after the request is received, the DME MAC will determine whether the request is valid or invalid and will notify the requestor of that determination. If the request is invalid, the DME MAC will explain why it was invalid. If the request is valid, within 90 days after the request is received, the DME MAC will make a reconsideration decision and will notify the requestor of the decision with its rationale. Decision options include: No revision Revision to a less restrictive policy Revision to a more restrictive policy, or Retiring the policy Any revision to the policy will then be published in a future update and posted to the DME MAC Web site. Scope of Policies The LCDs and Policy Articles address many of the most frequently ordered durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) items and services, but clearly not all. If coverage criteria for an item are not defined in a policy, then it means that only general coverage criteria apply, i.e. the item must fall within a benefit category, it must not be excluded by statute or by national CMS policy as described in the CMS IOM Publication 100-03, Medicare National Coverage Determinations 5 Jurisdiction B DME MAC Supplier Manual Chapter 5: Medical Policy Information [MARCH 2008] Manual and CMS IOM Publication 100-08, Medicare Program Integrity Manual, and it must be reasonable and necessary in the individual case for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. When coverage is addressed in the medical policy, it only refers to coverage of claims processed by the DME MAC under specific benefit categories. (Refer to the Benefit Categories section for more information.) The items described in the policies may be covered under other provisions of the law, e.g., as part of institutional care in a hospital or nursing facility, as an item incident to a physician’s service, etc. However, in these circumstances, the claim would not be submitted to the DME MAC and the coverage statements in the DME MAC policy may not apply. Individual Consideration In the medical policies, the stated coverage criteria represent the circumstances under which Medicare usually covers the item. However, the policies do not include every possible acceptable indication. Other indications can be considered for coverage if the denial or potential denial is based on a medical necessity decision by the DME MAC. (If the denial/potential denial is based on a benefit coverage determination—i.e., the policy states the item is “noncovered”—or on a national medical necessity policy, then an exception cannot be considered.) Other indication will be covered only if there is detailed documentation of the medical necessity for the item in the individual case. The nature and extent of the documentation required would have to be individualized based on the item in question. Some of the following information would likely be pertinent: The diagnosis relating to the need for the item Complicating medical conditions Functional abilities and limitations (e.g., the ability to ambulate or transfer, the amount of time in a bed, chair or wheelchair, the type and frequency of activities outside the home) The duration of the condition The overall course (improving or worsening) Rehabilitation potential (including recent prior functional level) Prognosis Description of and response to prior treatment Experience with similar items Physical examination findings, test results, etc. Documentation can be provided either with the initial claim or with an appeal. If it is provided with the initial claim, the supplier should include as much information as possible in the NTE (Note) segment of the electronic claim. For additional information regarding the LCD process, please refer to the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13. 6 Jurisdiction B DME MAC Supplier Manual Chapter 5: Medical Policy Information [MARCH 2008] CURRENT DMEPOS MEDICAL POLICIES The DMEPOS medical policies are no longer included in the Jurisdiction B DME MAC Supplier Manual. All DMEPOS medical policies can be located on the National Government Services Web site at www.adminastar.com/Providers/DMERC/MedicalPolicy/MedicalPolicy.cfm. 7 Jurisdiction B DME MAC Supplier Manual Chapter 6: Certificates of Medical Necessity/DME Information Forms [MARCH 2008] 6 Certificates of Medical Necessity/ DME Information Forms OVERVIEW A Certificate of Medical Necessity (CMN) or DME Information Form (DIF) is a form required to help document the medical necessity and other coverage criteria for selected durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) items. The Documentation section of each individual medical policy shows which items require one of these forms. CMNs contain sections A through D. Sections A and C are completed by the supplier and Sections B and D are completed by the physician. A DIF is completed and signed by the supplier. It does not require a narrative description of the equipment and cost or a physician signature. For certain items or services billed to the durable medical equipment Medicare administrative contractor (DME MAC), the supplier must receive a signed CMN from the treating physician or a signed DIF from the supplier. A supplier must have a faxed, photocopied, an original signed order or an electronic CMN or DIF in their records before they can submit a claim for payment to Medicare. The Centers for Medicare & Medicaid Services (CMS) form number is in the bottom left corner of the form. CMNs and DIFs are referred to by their CMS form numbers. DME form numbers identify the CMN on electronic claims submitted to the DME MAC. For example, CMS Form 484 serves as the CMN for oxygen. CMS Form 10125 serves as the DIF for External Infusion Pump. A faxed, photocopied, an original signed order, or an electronic signed CMN or DIF must be maintained by the supplier and be available to the DME MAC or zone program integrity contractors (ZPICs) on request. When hard-copy CMNs or DIFs are submitted to the DME MAC or ZPIC, the supplier must include a copy of only the front side. When CMNs are submitted electronically to the DME MAC or ZPIC, information from sections A and B are required. For additional requirements and instructions on how to properly complete CMNs and DIFs, please refer to the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.3, 5.3.1, 5.3.2, 5.3.3, 5.5, and 5.6. In 2006 CMS developed new and improved CMNs and DIFs. The official instruction regarding the form changes are located on the CMS Web site at www.cms.hhs.gov/Transmittals/downloads/R167PI.pdf. DME FORMS The following table indicates the DME CMN forms. DME Form 484.03 04.04B 04.04C CMS Form 484 846 847 Items Addresses Oxygen Pneumatic compression devices Osteogenesis stimulators 1 Jurisdiction B DME MAC Supplier Manual Chapter 6: Certificates of Medical Necessity/DME Information Forms [MARCH 2008] DME Form 06.03B 07.03A 11.02 CMS Form 848 849 854 Items Addresses Transcutaneous electrical nerve stimulators (TENS) Seat lift mechanisms Section C Continuation Form The following table indicates the DIFs for external infusion pumps and parenteral and enteral nutrition (PEN). DME Form 10.03 09.03 CMS Form 10126 10125 Items Addresses Enteral/parenteral nutrition External infusion pump EXTERNAL INFUSION PUMPS & ENTERAL/PARENTERAL NUTRITION For claims processed on or after July 1, 2007, the new DIFs will be the only forms accepted for external infusion pumps and parenteral and enteral nutrition (PEN). CMN/DIF COMPLETION INSTRUCTIONS In Section A, at least the patient’s name, address, telephone and Health Insurance Claim Number (HICN), the supplier’s name, address, telephone and National Supplier Clearinghouse (NSC) number and the Healthcare Common Procedure Coding System (HCPCS) codes must be completed by the supplier before the CMN is sent to the physician. The Initial Date in Section A should be either the specific date that the physician gives as the start of the medical necessity or, if the physician does not give a specific start date, the Initial Date should be the date of the verbal or preliminary order. Section B may not be completed by the supplier on the CMS forms 484, 846, 847, 848, and 849. Section B may be completed by the physician, the physician’s employee or another clinician involved in the care of the patient (e.g., nurse, physical or occupational therapist, etc.) as long as that person is not the supplier. Section C on the CMS forms 484, 846, 847, 848, and 849 reflects the requirements from the 1994 Amendments to the Social Security Act. It provides an opportunity for the ordering physician to review and confirm a detailed description of the items provided. It also indicates the supplier’s charge and what the Medicare fee schedule allowance will be, if applicable. Section C contains a blank space that can be formatted in different ways. However the following guidelines must be met. The description of the item provided must include not only those items listed in Section A of the CMN, but also any accessories, options, supplies or drugs which are related to the item and which are provided by the supplier. There should be a narrative description for each related item billed on a separate claim line. The exact HCPCS description is not required; a reasonable, abbreviated descriptor may be substituted. 2 Jurisdiction B DME MAC Supplier Manual Chapter 6: Certificates of Medical Necessity/DME Information Forms [MARCH 2008] For every item listed, the supplier must always specify their submitted charge. For purchased equipment, accessories and options, the full charge must be specified. For rental equipment, accessories and options, the supplier must specify “per month” or “/month.” For accessories, supplies, nutrients, or drugs which are replaced regularly, the supplier must specify what time span the charge represents, e.g., per day, per week, per month, etc. The supplier must list the Medicare fee schedule amount for each item, accessory and option, if applicable. The fee schedule allowance should reflect the same time span and quantity used in the submitted charge column. If the Medicare allowed amount is determined by methods other than a fee schedule (e.g., miscellaneous codes), a N/A (not applicable) should be put in the Medicare allowed charge column. Section C must be completed by the supplier before the CMN is sent to the physician. Samples of Section C formats are provided below within this chapter. Suppliers may use other formats as long as the required information is presented. Satisfactory completion of Section C will be assessed in postpayment audits. Civil monetary penalties can be assessed for failure to comply. Section D contains the physician’s attestation statement, physician’s signature, and date. The physician who signs the CMN must be the physician who is actively/presently treating the patient. Claims submitted with CMNs lacking a physician signature will be denied. Suppliers billing electronically must indicate presence of the physician’s signature as specified in the electronic billing instructions. The date in Section D must be the date that the physician signs the CMN. Both the signature and date must be personally entered by the physician and may not be a stamp. For codes requiring a CMN or DIF, the CMN/DIF must accompany claims for purchase of these items (including replacement), for the first month rental of equipment, for the initial provision of PEN nutrients and supplies, and for any required revised certifications/recertifications. Submitting CMNs/DIF when they are not required (e.g., subsequent months on rental items, oxygen or PEN when there is no change in the order and no requirement for recertification) may cause claims processing problems/delays and is discouraged. Because CMS forms 484, 846, 847, 848, and 849 have been approved by the Office of Management and Budget (OMB), when a CMN is submitted with a paper claim, the hard copy CMN must be an exact reproduction of the CMS form. However, when the CMN is submitted electronically to the DME MAC, the font on a hard copy CMN which the supplier retains in their files may be modified as follows: Pitch may vary from 10 characters per inch (CPI) to 17.7 CPI Line spacing must be 6 lines per inch Each CMN must have a minimum ¼-inch margin on all four sides Without exception, these modified hard-copy forms must contain identical questions/wording to the CMS forms, in the same sequence, with the same pagination and identical instructions/definitions printed on the back CMN question sets may not be combined 3 Jurisdiction B DME MAC Supplier Manual Chapter 6: Certificates of Medical Necessity/DME Information Forms [MARCH 2008] A nurse practitioner, clinical nurse specialist, or physician assistant may complete Section B and sign Section D if they meet all the requirements for them to sign orders as described in the Documentation chapter of this manual. For a CMN that is mailed or delivered to the physician, it must be a two-sided CMN. For a CMN that is faxed or sent electronically to the physician, the supplier must send the back of the CMN form as well as the front. If the supplier is faxing multiple CMNs to the physician at the same time, only one copy of the back of the form needs to be faxed. The physician must review, complete, and correct Section A as needed, complete Section B, review Section C, sign and date Section D, and send the completed CMN to the supplier. If any change is made to a CMN after the physician has completed Section B and signed Section D, the physician must line through the correction and initial and date the change or the supplier may choose to have the physician complete a new CMN. For a hard-copy CMN, the physician may either mail or fax the completed CMN to the supplier. When a physician faxes a completed CMN to the supplier or mails a completed CMN that they have received as a fax, the back of the CMN form does not need to be included. Upon request by the DME MAC, the supplier must provide in a timely manner the CMN that they received from the physician in a format that the DME MAC can accept. For medical review or appeals purposes, the DME MAC will accept any of the following forms of a CMN: An original “pen and ink” document A photocopy A facsimile image An electronically maintained document (An electronically maintained document is one which has been created modified, and stored via electronic means, such as commercially available software packages and servers.) When a claim is reviewed by the ZPIC as part of an investigation of potentially fraudulent behavior by a supplier, it will be the supplier’s responsibility to prove the authenticity/validity of the claim(s) under investigation. The DME MAC may require the supplier to prove the authenticity/validity of the signature on the CMN, or any other questionable portion of the claim(s) under investigation. Proof of the authenticity/validity of a signature may take a variety of forms. The ZPIC will determine the appropriate level of proof needed. For items that require a CMN, the supplier must have a fully completed CMN in their records before they submit a claim to the DME MAC. When a CMN/DIF is submitted hard copy to the DME MAC, the supplier must include a copy of only the front side. When a CMN is submitted electronically to the DME MAC, only information from Sections A, B, and D is transmitted. The date of service on the claim (which corresponds to the delivery date on claims for purchased items or on the first month’s claim for rental items) may be different than the Initial Date on the CMN. However, if the date of service on a claim is prior to the Initial Date on the CMN, the claim line will be denied as not medically necessary. Furthermore, to ensure that an item is still medically necessary when it is delivered, the delivery date must be within three months following the Initial Date on the CMN or within three months from the date of the physician’s signature. 4 Jurisdiction B DME MAC Supplier Manual Chapter 6: Certificates of Medical Necessity/DME Information Forms [MARCH 2008] CMS forms 484, 846, 847, 848, and 849 can serve as the physician order if the narrative description in Section C is sufficiently detailed. Refer to the Documentation chapter of this manual for the requirements of detailed written orders. For items which require a detailed written order prior to delivery and which have a CMN (i.e., air fluidized beds, TENS, seat lift mechanisms), suppliers may utilize a completed and physician-signed CMN for this purpose, if the CMN is signed and dated prior to delivery of the item. Otherwise, a separate detailed written order in addition to a subsequently completed and signed CMN would be necessary. The physician is encouraged, although not required, to keep a copy of the CMN in their patient’s medical record. CMNs are a standardized means of submitting some medical necessity information to the DME MACs. A CMN does not by itself provide sufficient documentation of medical necessity, even though it is signed by the treating physician. There must be clinical information in the patient’s medical record which substantiates the answers on the CMN and supports the medical necessity for the item in the individual case. CMNs will be audited periodically to validate proper completion and transmission to the DME MAC and to verify that the answers on CMNs are supported by information in the patient’s medical record. If the information contained in either the supplier’s records or in the patient’s medical record fails to substantiate the CMN, or if it appears that the CMN has been altered, the item will be considered not medically necessary and a denial or overpayment will be initiated. COVER LETTERS Cover letters may be used by a supplier as a method of communication between themselves and the physician. There is no restriction on the content of cover letters. However, suppliers should remind physicians that it is their responsibility to determine the medical need for, and the utilization of, all health care services. Suppliers are also encouraged to remind physicians that it is the physician’s responsibility to ensure that the information on the CMN relating to the beneficiary’s condition is correct and is supported by information in the patient’s medical record. SECTION C EXAMPLE Item: Codes: HCPCS Description: A B C D E0781 A4222 A4221 J2270 Ambulatory infusion pump Supplies for external drug infusion pump, per cassette or bag Supplies for maintenance of drug infusion catheter, per week Morphine sulfate, 10 mg 5 Jurisdiction B DME MAC Supplier Manual Chapter 6: Certificates of Medical Necessity/DME Information Forms [MARCH 2008] Item: Quantity: Supplier’s Charge: Medicare Fee Schedule Allowance: A B C D 1 3/week 1/week 168/week $747.30/month $153.30/week $30.00/week $300.00/week $235.28/month $121.44/week $20.39/week N/A* * A not applicable (N/A) entry means that Medicare payment will be determined by a method other than a fee schedule; it does not indicate that Medicare will deny the item. SAMPLE CMN FORMS The following pages provide photocopy-ready samples of all the DME forms. Instructions for completion of the CMNs/DIFs are included within this chapter and should be reviewed and followed. The DME forms are located on the National Government Services at www.adminastar.com/Providers/DMERC/MedicareManuals/pubcmn.htm. The new DME forms can also be accessed from the CMS Web site at www.cms.hhs.gov/CMSForms/CMSForms/list.asp. HCPCS CODES REQUIRING A CMN OR A DIF The following HCPCS codes are those which require a CMN/DIF on claims that should be listed in Section A of the CMN/DIF. For narrative descriptions, refer to the specific local coverage determination and policy article, and/or the HCPCS Coding page on the National Government Services Web site at http://www.adminastar.com/Providers/DMERC/HCPCSCodes/HCPCSCodes.html. B4034 B4160 B4197 B9006 E0444 E0668 E0779 J0287 J1817 J9065 B4035 B4161 B4199 E0424 E0627 E0669 E0780 J0288 J2175 J9100 B4036 B4162 B4216 E0425 E0628 E0671 E0781 J0289 J2260 J9110 B4149 B4164 B4220 E0430 E0629 E0672 E0784 J0895 J2270 J9190 B4150 B4168 B4222 E0431 E0650 E0673 E0791 J1170 J2271 J9200 B4152 B4172 B4224 E0434 E0651 E0720 E1390 J1250 J2275 J9360 B4153 B4176 B5000 E0435 E0652 E0730 E1391 J1265 J2278 J9370 6 B4154 B4178 B5100 E0439 E0655 E0731 E1392 J1325 J3010 J9375 B4155 B4180 B5200 E0440 E0660 E0747 E1405 J1455 J3285 J9380 B4157 B4185 B9000 E0441 E0665 E0748 E1406 J1457 J7500 K0455 B4158 B4189 B9002 E0442 E0666 E0760 J0133 J1562 J9000 K0738 B4159 B4193 B9004 E0443 E0667 E0776 J0285 J1570 J9040 Jurisdiction B DME MAC Supplier Manual Chapter 7: Documentation [MARCH 2008] 7 Documentation ORDERS Dispensing Orders Before dispensing any durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item to a beneficiary, the supplier must have an order from the treating physician. Except for items requiring a detailed written order prior to delivery, the “dispensing” order may be either a verbal order or a preliminary written order (original “pen and ink,” facsimile image, photocopy, signature stamp, or electronic). Verbal orders must be documented in the patient’s file. The dispensing order must contain a description of the item, the name of the beneficiary, the name of the physician, and the start date of the order. The dispensing order does not need to be as comprehensive as the detailed written order, which is required before submitting a claim (see following section). For items that are dispensed based on a verbal order, the supplier must obtain a detailed written order before submitting a claim (see following section). The supplier must maintain written documentation of the dispensing order and this documentation must be available to the durable medical equipment Medicare administrative contractor (DME MAC) upon request. Except for items requiring a detailed written order prior to delivery, if the supplier does not have an order from the treating physician before dispensing an item, it will be denied as not medically necessary. A detailed written order prior to delivery is required for the following: Pressure reducing pads, mattress overlays, mattresses, and beds Seat lift mechanisms Transcutaneous electrical nerve stimulation (TENS) units Power operated vehicles Power wheelchairs Wheelchair seating Negative pressure wound therapy pumps The supplier must have a detailed written order for these items (see following section)—original “pen and ink,” facsimile image, photocopy, or electronic—which has been both signed and dated by the treating physician before dispensing the item. For these items, if the supplier does not have a detailed written order prior to delivery, it will be denied as statutorily noncovered. Detailed Written Orders Before submitting a claim for any DMEPOS item to the DME MAC, the supplier must have a detailed written order (original “pen and ink,” signature stamp, facsimile image, photocopy, or electronic) which has been both signed and dated by the treating physician. This detailed written order is in addition to the dispensing order described above, unless the dispensing order meets all the requirements specified in this section. 1 Jurisdiction B DME MAC Supplier Manual Chapter 7: Documentation [MARCH 2008] The supplier may not submit a claim based only on a verbal order. If an item requires a Certificate of Medical Necessity (CMN), and if the CMN contains all the information described in this section, it may serve as the detailed written order. Except for items requiring a detailed written order prior to delivery, if the supplier does not have a detailed written order for an item prior to submitting a claim, it will be denied as not medically necessary. For items requiring a detailed written order prior to delivery (see Dispensing Orders section), if the order has not been obtained, the item will be denied as statutorily noncovered. CMNs for parenteral and enteral nutrition (PEN) and external infusion pumps were replaced by the DME MAC Information Forms (DIFs) for claims with dates of service on or after January 1, 2007. DIFs are completed by the supplier and physicians do not have to review and sign them. However, since the CMNs usually served as the detailed written order, suppliers will now have to obtain the detailed written order using a different document for PEN and external infusion pump claims. The detailed written order must contain the beneficiary’s name, the signature of the treating physician and the date that the order is signed. All orders must clearly specify the start date of the order. The date that the order is signed will be considered the start date unless a separate start date is entered. If the order is for an item that has been dispensed before the date that the detailed written order is signed (e.g., a written confirmation of a verbal order), then the order must clearly specify the start date in addition to the signature date. The detailed written order (required before submitting a claim) must be sufficiently detailed, including all options or additional features which will be separately billed or which will require an upgraded code. The description can be either a narrative description (e.g., lightweight wheelchair base) or a brand name/model number. If the order is for a rented item or if the coverage criteria in a policy specify length of need, the order must include the length of need. If the order is for accessories or supplies that will be provided on a periodic basis, the order should include appropriate information on the quantity used, frequency of change or use, and length of need. (For example, an order for surgical dressings might specify one 4 × 4 hydrocolloid dressing that is changed 12 times per week for one month or until the ulcer heals.) If the supply is a drug, the order must specify the name of the drug, concentration (if applicable), dosage, frequency of administration, and duration of infusion (if applicable). The detailed description of the item may be completed by someone other than the physician. However, the treating physician must review the detailed description and personally sign and date the order to indicate agreement. Upon request by the DME MAC and/or the zone program integrity contractor (ZPIC), the supplier must provide in a timely manner the detailed written order that they received from the physician in a format that the DME MAC and/or ZPIC can accept. For medical review or appeals purposes, the DME MAC and/or ZPIC will accept any of the following forms of an order: An original “pen and ink” document A photocopy A facsimile image, or An electronically maintained document 2 Jurisdiction B DME MAC Supplier Manual Chapter 7: Documentation [MARCH 2008] Note: An electronically maintained document is one that has been created, modified and stored via electronic means, such as commercially available software packages and servers. When a claim is reviewed by the ZPIC as part of an investigation of potentially fraudulent behavior by a supplier, it will be the supplier’s responsibility to prove the authenticity/validity of the claim(s) under investigation. The ZPIC may require the supplier to prove the authenticity/validity of the signature on the order, or any other questionable portion of the claim(s) under investigation. Proof of the authenticity/validity of a signature may take a variety of forms. The ZPIC will determine the appropriate level of proof needed. For additional instructions regarding physician orders, verbal orders, preliminary written orders, and detailed written orders prior to delivery, please refer to the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2, 5.2.1, 5.2.2, 5.2.3, 5.2.3.1. Requirements for New Orders A new order is required when there is a change in the order for the accessory, supply, drug, etc. A new order is required on a regular basis (even if there is no change in the order) only if it is so specified in the Documentation section of a particular medical policy. A new order is required when an item is replaced. A new order is also required when there is a change in supplier. In cases where two or more suppliers merge, the resultant supplier should make all reasonable attempts to secure copies of all active orders from the supplier(s) purchased. This document should be kept on file by the resultant supplier and be available to the DME MAC on request. For additional requirements for new orders please refer to the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4. Special Rules for Nurse Practitioners and Clinical Nurse Specialists A nurse practitioner or clinical nurse specialist may provide the dispensing order and sign the detailed written order if they satisfy all the following requirements: They They They They are treating the beneficiary for the condition for which the item is needed, and are practicing independently of a physician, and bill Medicare for other covered services using their own provider number, and are permitted to do all of the above in the state in which the services are rendered Special Rules for Physician Assistants A physician assistant may provide the dispensing order and may document and sign the detailed written order if they satisfy all the following requirements: 3 Jurisdiction B DME MAC Supplier Manual Chapter 7: Documentation [MARCH 2008] They meet the definition of a physician assistant found in Section 1861(aa)(5) of the Social Security Act or Section 2156(A) of the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.5 and 5.6, and They are treating the beneficiary for the condition for which the item is needed, and They are practicing under the supervision of a doctor of medicine or doctor of osteopathy, and They have their own Unique Physician Identification Number (UPIN), and They are permitted to perform services in accordance with state law For additional requirements regarding nurse practitioners, clinical nurses and physician assistants please refer to the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.5 and 5.6. Medical necessity information (e.g., an ICD-9 diagnosis code, narrative description of the patient’s condition, abilities, limitations, etc.) is not considered part of the order; although it may be entered on the same document as the order. CERTIFICATES OF MEDICAL NECESSITY Please refer to the Certificates of Medical Necessity chapter of this manual for detailed information regarding this subject. DOCUMENTATION IN THE PATIENT’S MEDICAL RECORD For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient’s diagnosis and other pertinent information including, but not limited to, duration of the patient’s condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitation, other therapeutic interventions and results, past experience with related items, etc. If an item requires a CMN, it is recommended that a copy of the completed CMN be kept in the patient’s record. However, neither a physician’s order nor a CMN nor a supplier-prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician. There must be clinical information in the patient’s medical record which supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or information on a supplier-prepared statement or physician attestation (if applicable). The patient’s medical record is not limited to the physician’s office records. It may include hospital, nursing home or home health agency records, and records from other professionals including, but not limited to, nurses, physical or occupational therapists, prosthetists, and orthotists. The documentation in the patient’s medical record does not have to be routinely sent to the supplier or to the DME MAC. However, the DME MAC may request this information in selected cases. If the DME MAC does not receive the information when requested, or if the information in the patient’s 4 Jurisdiction B DME MAC Supplier Manual Chapter 7: Documentation [MARCH 2008] medical record does not adequately support the medical necessity for the item, then (on assigned claims) the supplier is liable for the dollar amount involved unless a properly executed advance beneficiary notice (ABN) of possible denial has been obtained. For additional documentation requirements, please refer to the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.7 and 5.8. PROOF OF DELIVERY REQUIREMENTS Documentation Requirements Suppliers are required to maintain proof of delivery documentation in their files. Documentation must be maintained in the supplier’s files for seven years. Proof of delivery is required in order to verify that the beneficiary received the DMEPOS. Proof of delivery is one of the supplier standards as noted in 42 CFR, 424.57(12). Proof of delivery documentation must be made available to the DME MAC upon request. For any services, which do not have proof of delivery from the supplier, such claimed items and services shall be denied and overpayments recovered. Suppliers who consistently do not provide documentation to support their services may be referred to the Office of the Inspector General for investigation and/or imposition of sanctions. Delivery Methods Note: For the purpose of the delivery methods noted below, the designee is defined as: “Any person who can sign and accept the delivery of durable medical equipment on behalf of the beneficiary.” Suppliers, their employees or anyone else having a financial interest in the delivery of the item are prohibited from signing and accepting an item on behalf of a beneficiary (i.e., acting as a designee on behalf of the beneficiary). The relationship of the designee to the beneficiary should be noted on the delivery slip obtained by the supplier (i.e., spouse, neighbor, etc.). The signature of the designee should be legible. If the signature of the designee is not legible, the supplier/shipping service should note the name of the designee on the delivery slip. Method 1—Direct Delivery to the Beneficiary By the Supplier Suppliers may deliver directly to the beneficiary or the designee. An example of proof of delivery to a beneficiary would be having a signed delivery slip. It is recommended that the delivery slip include: 1) 2) 3) 4) 5) The patient’s name The quantity delivered A detailed description of the item being delivered The brand name, and The serial number 5 Jurisdiction B DME MAC Supplier Manual Chapter 7: Documentation [MARCH 2008] The date of signature on the delivery slip must be the date that the DMEPOS item was received by the beneficiary or designee. In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply shall be the date of service on the claim. Method 2—Delivery via Shipping or Delivery Service If the supplier utilizes a shipping service or mail order, an example of proof of delivery would include the service’s tracking slip and the supplier’s own shipping invoice. If possible, the supplier’s records should also include the delivery service’s package identification number for that package sent to the beneficiary. The shipping service’s tracking slip should reference the following: Each individual package The delivery address The corresponding package identification number given by the shipping service, and The date delivered (if possible) If a supplier utilizes a shipping service or mail order, suppliers shall use the shipping date as the date of service on the claim. Suppliers may also utilize a return postage-paid delivery invoice from the beneficiary or designee as a form of proof of delivery. The descriptive information concerning the DMEPOS item (i.e., the patient’s name, the quantity, detailed description, brand name, and serial number), as well as the required signatures from either the beneficiary or the beneficiary’s designee, should be included on this invoice as well. For DMEPOS products that are supplied as refills to the original order, suppliers must contact the beneficiary prior to dispensing the refill. This shall be done to ensure that the refilled item is necessary and to confirm any changes/modifications to the order. Contact with the beneficiary or designee regarding refills should take place no sooner than approximately seven days prior to the delivery/shipping date. For subsequent deliveries of refills, the supplier should deliver the DMEPOS product no sooner than approximately five days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. DME MACs shall allow for the processing of claims for refills delivered/shipped prior to the beneficiary exhausting his/her supply. Method 3—Delivery to Nursing Facility on Behalf of a Beneficiary When a supplier delivers items to a nursing facility, the documentation described for Method 1 is required. When a delivery service is used to deliver the item to a nursing facility, the documentation described for Method 2 is required. For those patients that are residents of a nursing facility, upon request from the DME MAC, suppliers should obtain copies of the necessary documentation from the nursing facility to document proof of delivery or usage by the beneficiary (e.g., nurse’s notes). 6 Jurisdiction B DME MAC Supplier Manual Chapter 7: Documentation [MARCH 2008] Items Provided in Anticipation of Discharge from a Hospital or Skilled Nursing Facility Exceptions to the preceding statements concerning the date(s) of service on the claim occur when the items are provided in anticipation of discharge from a hospital or nursing facility. A supplier may deliver a DMEPOS item to a patient in a hospital or nursing facility for the purpose of fitting or training the patient in the proper use of the item. This may be done up to two days prior to the patient’s anticipated discharge to their home. The supplier shall bill the date of service on the claim as the date of discharge and shall use the place of service (POS) code 12 (patient’s home). The item must be for subsequent use in the patient’s home. No billing may be made for the item on those days the patient was receiving training or fitting in the hospital or nursing facility. A supplier may not bill for drugs or other DMEPOS items used by the patient prior to the patient’s discharge from the hospital or a Medicare Part A nursing facility stay. Billing the DME MAC for surgical dressings, urological supplies, or ostomy supplies that are provided in the hospital or during a Medicare Part A nursing facility stay is not allowed. These items are payable to the facility under Part A of Medicare. This prohibition applies even if the item is worn home by the patient from the hospital or nursing facility. Any attempt by the supplier and/or facility to substitute an item that is payable to the supplier for an item that, under statute, should be provided by the facility, may be considered to be fraudulent. These statements apply to durable medical equipment delivered to a patient in hospitals, skilled nursing facilities (POS = 31), or nursing facilities providing skilled services (POS = 32). A supplier may deliver a DMEPOS item to a patient’s home in anticipation of a discharge from a hospital or nursing facility. The supplier may arrange for actual delivery of the item approximately two days prior to the patient’s anticipated discharge to their home. The supplier shall bill the date of service on the claim as the date of discharge and should use the POS code 12 (patient’s home). REQUESTS FOR ADDITIONAL INFORMATION If the original claim and CMN do not contain all the information required to determine the medical necessity of the supply or item, the DME MAC may request additional information from the supplier, the ordering physician or the beneficiary through the Additional Documentation Request (ADR) process. Suppliers/physicians will be allowed 30 days to respond to ADR letters. If after 30 days the DME MAC has received no response, the DMEPOS item will be denied for lack of information. The Jurisdiction B DME MAC ADR address is: National Government Services, Inc. Additional Documentation Requests P.O. Box 7061 Indianapolis, Indiana 46207-7061 7 Jurisdiction B DME MAC Supplier Manual Chapter 8: Advance Determination of Medicare Coverage [MARCH 2008] 8 Advance Determination of Medicare Coverage Advanced Determination of Medicare Coverage (ADMC) is a process by which the durable medical equipment Medicare administrative contractor (DME MAC) will provide the requestor with a coverage decision prior to delivery of an item. ELIGIBLE ITEMS ADMC will be available only for the following wheelchair base Healthcare Common Procedure Code System (HCPCS) codes and related options and accessories: E1161 E1231 E1232 E1233 E1234 K0005 K0009 Manual adult size wheelchair, includes tilt in space Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system Ultralightweight manual wheelchair Not otherwise classified manual wheelchair base Power wheelchairs: Group Group Group Group Group 2 3 4 5 3 Group 4 (K0835–K0843) (K0856–K0864) (K0877–K0886) (K0890, K0891) (K0848–K0855) provided with an alternative drive control interface (E2321–E2322, E2325, E2327–E2330) (K0868–K0871) provided with an alternative drive control interface (E2321–E2322, E2325, E2327–E2330) New HCPCS within the Power Mobility Device Local Coverage Determination (LCD) L21271 are in effect for Advance Determination of Medicare Coverage (ADMC) submissions received on or after November 15, 2006. All ADMC requests providing the old HCPCS will be rejected. Note: When a particular wheelchair base is eligible for ADMC, all wheelchair options and accessories ordered by the physician for that patient along with the base HCPCS code will be eligible for ADMC. SUBMITTING ADMC REQUESTS Effective February 18, 2008, all ADMC requests must be sent to National Government Services due to the medical review transition from the program safeguard contractors (TriCenturion) to the DME MACs. 1 Jurisdiction B DME MAC Supplier Manual Chapter 8: Advance Determination of Medicare Coverage [MARCH 2008] ADMC requests may either be mailed or sent by fax. ADMC requests cannot be submitted electronically. When submitting an ADMC request either by mail or fax, please include the ADMC cover sheet (located at the end of this chapter) with each request. The mailing address for ADMC requests is: National Government Services, Inc. Attn: Medical Review—ADMC P.O. Box 6036 Indianapolis, Indiana 46206-6036 Fax ADMC information to 317-595-4759 ADMC cover sheets are located on the National Government Services Web site at http://www.adminastar.com/Providers/DMERC/Forms/files/ADMCForm.pdf. ADMC REQUIREMENTS Certificates of Medical Necessity (CMNs) for manual and power wheelchair bases were discontinued effective April 1, 2006, prompting questions about what information should be submitted to support an ADMC request. Because CMNs are no longer required and will not be used for the submission of wheelchair claims, the first page of the ADMC request must contain all of the following demographic information: Beneficiary information − Name − Health Insurance Claim Number (HIC #) − Address − Date of birth Place of service ICD-9 diagnosis code (narrative description is not sufficient) Supplier information − Name − National Supplier Clearinghouse (NSC) number − Address − Phone number Physician’s information − Name − Unique Physician Identification Number (UPIN) − Address − Phone number Note: If the information listed above is not present, ADMC requests received by the DME MACs will be rejected. 2 Jurisdiction B DME MAC Supplier Manual Chapter 8: Advance Determination of Medicare Coverage [MARCH 2008] Manual Wheelchairs For manual wheelchairs, the supplier must include the following (1–3): 1) A detailed written order that lists the specific wheelchair base that is to be provided and each option/accessory that will be separately billed. The order must also specify which HCPCS code is associated with each item on the order. This information may be entered by the supplier but the order must be signed and dated by the physician. 2) Information from the patient’s medical record that documents that the coverage criteria defined in the medical policy on Manual Wheelchairs have been met. 3) A home assessment which establishes that the beneficiary or caregiver is able to use the wheelchair ordered to assist with activities of daily living (ADLs) in the home. For more information on coverage criteria, coding guidelines and documentation requirements, refer to the medical policies for Manual Wheelchairs, Wheelchair Options and Accessories, and Wheelchair Seating on the National Government Services Web site at www.adminastar.com/Providers/DMERC/MedicalPolicy/MedicalPolicy.cfm. Power Wheelchairs For power wheelchairs, the supplier must include all of the following items (1–4): 1) The order that the supplier received within 45 days following the completion of the face-to-face examination. This order must contain the following elements: Beneficiary name Description of the item. This may be general, e.g., “power wheelchair” or “power mobility device,” or may be more specific. Date of the face-to-face examination. If the evaluation involved multiple visits, enter the date of the last visit. (Refer to the Power Wheelchairs policy for additional information.) Pertinent diagnoses/conditions that relate to the need for the power wheelchair Length of need Physician’s signature Date of physician signature There must be a date stamp or equivalent on the order to indicate when it was received by the supplier. 2) A detailed product description (which includes information previously contained in the detailed written order) that lists the specific wheelchair base that is to be provided and each option/accessory that will be separately billed. This document must also specify which HCPCS code is associated with each item on the list. This information may be entered by the supplier but the document must be signed and dated by the physician. (The signature date on this document does not have to be within 45 days following the face-to-face exam.) For ADMC 3 Jurisdiction B DME MAC Supplier Manual Chapter 8: Advance Determination of Medicare Coverage [MARCH 2008] requests that are received on or after August 24, 2006, the document must also include the supplier’s charge and the Medicare fee schedule allowance for each item. If there is no fee schedule allowance, enter “Not Applicable.” 3) A copy of the report of the face-to-face examination by the physician—and other licensed/certified medical professionals (LCMPs), if applicable. There must be a date stamp or equivalent on the report(s) to indicate when they were received by the supplier. For ADMC requests received on or after August 10, 2006, LCMPs reports that are to be considered part of the face-to-face examination must include an attestation statement from the supplier indicating that the LCMP has no financial relationship with the supplier. Refer to the Power Wheelchairs policy for guidance on the type of documentation to be included. Note: If the power wheelchair is a replacement within five years of one billed with the same HCPCS code that was previously covered by Medicare, a face-to-face examination is not required. 4) A home assessment which establishes that the beneficiary is able to use the wheelchair ordered to assist with ADLs in the home. For more information on coverage criteria, coding guidelines, and documentation requirements, refer to the medical policies for Motorized/Power Wheelchairs, Wheelchair Options and Accessories and Wheelchair Seating on the National Government Services Web site at www.adminastar.com/Providers/DMERC/MedicalPolicy/MedicalPolicy.cfm. Additional Guidance Any information provided that explains the medical necessity for separately billed options and accessories must use the same short description for the item that is used in the detailed product description or detailed written order. If the patient’s weight and/or height are needed to support the medical necessity for items that are ordered, that information should be included on the first page of the ADMC request. Even if the majority of the face-to-examination is performed by an LCMP, the ADMC request must also include the report of the face-to-face examination with the physician. Include the manufacturer, the product name, the model number and the width of wheelchair cushion(s) that are provided. Make certain that the product is listed on the Statistical and Analysis Durable Medical Equipment Medicare Regional Carrier (SADMERC) Product Classification List and that the HCPCS code on the ADMC is the one specified by the SADMERC. Suppliers are reminded that if an affirmative determination is made on the wheelchair base but individual options/accessories are denied, there may be no resubmission or other request for an ADMC determination on these. If these items are provided and denied at the time of claim submission, the supplier may present additional information to justify coverage through the appeals process. 4 Jurisdiction B DME MAC Supplier Manual Chapter 8: Advance Determination of Medicare Coverage [MARCH 2008] ADMC DETERMINATION Upon receipt of an ADMC request, the DME MAC Medical Review Department will make a determination within 30-calendar days. The DME MAC Medical Review Department will provide the supplier and beneficiary with its determination, either affirmative or negative, in writing. If it is a negative determination, the letter will indicate why the request was denied, e.g., not medically necessary, insufficient information submitted to determine coverage, statutorily noncovered. If a wheelchair base receives a negative determination, all accessories will also receive a negative determination. If a wheelchair base receives an affirmative determination, each accessory will receive an individual determination. Affirmative Determination An affirmative determination only relates to whether the item is medically necessary based on the information submitted. An affirmative determination does not provide assurance that the beneficiary meets Medicare eligibility requirements nor does it provide assurance that any other Medicare requirements (e.g., place of service, Medicare Secondary Payer) have been met. Only upon submission of a complete claim can the DME MAC Medical Review Department make a full and complete determination. An affirmative determination does not extend to the price that Medicare will pay for the item. Finally, the DME MAC Medical Review Department may review selected claims on a prepayment or postpayment basis and may deny a claim or request an overpayment if it determined that an affirmative determination was made based on incorrect information. An affirmative ADMC is only valid for items delivered within six months following the date of the determination. If the wheelchair is not delivered within that time, the supplier has the option of either submitting a new ADMC request (prior to providing the item) or filing a claim (after providing the item). If the item is provided within six months following an affirmative determination, and if the claim is for all the same items that were listed on the ADMC request, the documentation that supports the medical necessity of the item does not need to be submitted with the claim. If any of the items on the ADMC request were described by HCPCS code K0108 and if those items were provided, the supplier must ensure that the narrative description used on the claim matches the narrative description used on the ADMC determination letter. If a wheelchair base receives an affirmative determination, the supplier may not submit a separate ADMC request for additional accessories. If options or accessories are provided that were not listed on the ADMC request, the supplier should submit whatever information is appropriate to document the medical necessity for the new item(s). Negative Determination A negative ADMC determination may not be appealed because it does not meet the regulatory definition of an initial determination since no request for payment is being made. However, if the ADMC request for the wheelchair base is denied and the supplier obtains additional medical documentation, an ADMC request may be resubmitted. ADMC requests may only be resubmitted once during the six-month period following a negative determination. If the wheelchair base is approved, but one or more accessories are denied, an ADMC request may not be resubmitted for those 5 Jurisdiction B DME MAC Supplier Manual Chapter 8: Advance Determination of Medicare Coverage [MARCH 2008] accessories. If a supplier provides a wheelchair and/or accessories following a negative determination, a claim for the item should be submitted. If new information is provided with the claim, coverage will be considered. If the claim is denied, it may be appealed through the usual process. 6 Jurisdiction B DME MAC Advance Determination of Medicare Coverage (ADMC) Request Form ADMC HCPCS Code(s) and narrative for base wheelchair Note: Please submit this form along with supporting medical necessity documentation. Company Name: __________________________________________________________________ Company Address: __________________________________________________________________ __________________________________________________________________ Supplier Number: __________________________________________________________________ Contact Name: __________________________________________________________________ Telephone Number: __________________________________________________________________ Beneficiary Name: __________________________________________________________________ Beneficiary Address: __________________________________________________________________ __________________________________________________________________ HICN Number: __________________________________________________________________ Date of Birth: __________________________________________________________________ Place of Service: __________________________________________________________________ ICD 9: __________________________________________________________________ Physician’s Name: __________________________________________________________________ Physician’s Address: __________________________________________________________________ __________________________________________________________________ Telephone Number: __________________________________________________________________ UPIN: __________________________________________________________________ Number of Pages (including coversheet): _______________ Mail To: Fax To: National Government Services 1‐317‐595‐4759 Attn: Medical Review ‐ ADMC P.O. Box 6036 Indianapolis, In. 46206‐6036 National Government Services, Inc. Revised 1/07 Jurisdiction B DME MAC Supplier Manual Chapter 9: Advance Beneficiary Notice [DECEMBER 2007] 9 Advance Beneficiary Notice GENERAL GUIDELINES Advance Beneficiary Notice (ABN) is a written notice the supplier gives to a Medicare beneficiary before providing items and/or services that are expected to be denied by Medicare based on one of the following statutory exclusions: Lack of medical necessity Prohibited, unsolicited telephone contacts No supplier number Denial of Advanced Determination of Medicare Coverage (ADMC) request Suppliers must use the OMB-approved ABN form CMS-R-131 (ABN-G), which is located later in this chapter. For an ABN to be acceptable, it must: be on the approved CMS-R-131 form; clearly identify the particular item and/or service; state that the supplier believes Medicare is likely (or certain) to deny payment for the particular item and/or service; and give the supplier’s reason(s) for their belief that Medicare is likely (or certain) to deny payment for the item and/or service. The ABN is designed for use with Medicare beneficiaries only (including those who are dually-eligible for both Medicare and Medicaid). The ABN is not used for patients who are not Medicare beneficiaries. The purpose of the ABN is to inform a Medicare beneficiary, before he or she receives specified items and/or services that otherwise might be paid for, that Medicare probably will not pay for them on that particular occasion. The ABN also allows the beneficiary to make an informed consumer decision on whether or not to receive the items and/or services for which he or she may have to pay “out-ofpocket” through other insurance coverage (e.g., employer group health plan coverage), through Medicaid or other federal/nonfederal payment source. For assigned and nonassigned claims that have been denied as not medically necessary, the supplier will be held liable for the item and/or service and may not bill or collect from the beneficiary unless the supplier provided advance notice to the beneficiary in writing before providing the item/service stating that the beneficiary agreed to pay for the item/service if it is denied by Medicare. If these conditions are met, the beneficiary would be liable for payment to the supplier if Medicare denies the claim for the reason listed on the ABN. To be held liable for payment means that the beneficiary will be liable for payment “out-of-pocket,” or through other insurance coverage (e.g., employer group health plan coverage), or through Medicaid or other federal or nonfederal payment source. The ABN requirements apply to both assigned and nonassigned claims, as there are financial liability provisions under Medicare law. 1 Jurisdiction B DME MAC Supplier Manual Chapter 9: Advance Beneficiary Notice [DECEMBER 2007] A single ABN covering an extended course of treatment is acceptable provided the ABN identifies all items and services for which the physician or supplier believes Medicare will not pay. If as extended course of treatment progresses and additional items or service are to be furnished for which the physician or suppliers believes Medicare will not pay, the supplier must separately notify the beneficiary in writing (i.e., give the beneficiary another ABN) that Medicare is not likely to pay for the additional items or services and obtain the beneficiary’s signature on the ABN. One year is the limit for use of a single ABN for an extended course of treatment; if the course of treatment extends beyond one year, a new ABN is required for the remainder of the course of treatment. An ABN, once signed by the beneficiary, may not be modified or revised. When a beneficiary must be notified of new information, a new ABN must be given. LIMITATION ON LIABILITY Limitation on liability applies to assigned claims for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) services that have been disallowed due to: medical necessity; prohibition on unsolicited telephone calls; no supplier number; or no ADMC. Under limitation on liability, a beneficiary can be held liable for an item and/or service denied due to reasons cited on the ABN. Refund requirements apply to both assigned and nonassigned claims for DMEPOS services disallowed because of medical necessity, prohibition on unsolicited telephone contacts, supplier number, or no ADMC. The refund requirements state that suppliers must make refunds of any amounts collected if the beneficiary was not properly notified of possible disallowed Medicare claims. It is the supplier’s responsibility to notify the beneficiary in writing before providing an item or service, so that the beneficiary understands they will be held responsible for payment due to the item and/or service never being covered because it is not reasonable or necessary. Modifier GA should be reported in Box 24D of the CMS-1500 claim form with the appropriate Healthcare Common Procedure Coding System (HCPCS) code when the claim is filed for payment. The use of modifier GA is not optional and must be used anytime an ABN has been obtained. Modifier GZ should be reported in Box 24D of the CMS-1500 claim form when the physician or supplier needs to indicate that a denial is expected, but there is no ABN on file. If Medicare denies a claim as not medically necessary, but the supplier believes the service/item is medically necessary, the supplier should request a review of the claim. If the supplier chooses to request a review, suppliers should include any additional information necessary to support the claim. If a supplier requests a review within 30 days, they may delay refunding to the beneficiary until Medicare makes a determination on the review request. If the review request renders a favorable decision, the supplier is not required to refund the beneficiary for the item or service in question. If the review 2 Jurisdiction B DME MAC Supplier Manual Chapter 9: Advance Beneficiary Notice [DECEMBER 2007] request renders an unfavorable decision, the supplier must refund any monies collected for the item and/or service in question to the beneficiary within 15 days of receiving the review decision. The Medicare beneficiary will be notified of all review activity. A supplier may submit a review request any time within 120 days of receiving the initial determination, however in order to delay refunding the patient suppliers must submit a review request within 30 days of the initial determination. Modifiers That May Be Associated with ABNs GA GZ GK GL Waiver of liability (expected to be denied as not reasonable and necessary, ABN on file) Item or service not reasonable and necessary (expected to be denied as not reasonable and necessary, no ABN on file) Actual item/service ordered by physician, item associated with a GA or GZ modifier Medically unnecessary upgrade provided instead of nonupgraded item, no charge, no ABN UPGRADES CMS defines an upgrade as an item that is more expensive, contains more components or features, or is greater in quantity than what the physician ordered. Medicare will accept ABNs on upgrades. The upgraded item must be within the range of services that are appropriate for the beneficiary’s medical condition (e.g., beneficiary can upgrade from a standard manual wheelchair to a power wheelchair, but not from a walker to a wheelchair). The beneficiary has the choice on whether or not to upgrade. If the supplier believes the upgrade is more than what Medicare considers medically necessary an ABN may still be used in this situation, but the supplier must follow the current guidelines that are in place for the use of ABNs. The supplier would bill the appropriate DME MAC by providing the item/service that the physician ordered on one claim along with the GA modifier on the same line. If the beneficiary agrees to be financially liable by signing an ABN, a supplier may collect the difference between the charges for the upgraded item and the charges for the nonupgraded item. ABNs for upgrades apply to both assigned and nonassigned claims. A supplier may decide to provide a free upgrade for a beneficiary. When providing a free upgrade, the supplier should not have the beneficiary sign an ABN, because the supplier should not be charging more than the normal deductible and co-payment for the nonupgraded item. When providing a free upgrade, suppliers should use the appropriate HCPCS code for the nonupgraded item/service that the physician ordered. Suppliers should add the modifier GL with the correct HCPCS code. The supplier should specify the make and model of the upgraded item/service that was provided in Box 19 of the CMS-1500 form or as an attachment to the claim. The supplier should also describe why the item/service was an upgrade. When billing electronically, suppliers should provide this same information in the Note segment of the electronic claim. 3 Jurisdiction B DME MAC Supplier Manual Chapter 9: Advance Beneficiary Notice [DECEMBER 2007] The following examples explain how to file claims with an ABN and without an ABN: Upgraded with an ABN Item ordered by the physician Upgrade without an ABN Item ordered by the physician K0004RRKHGA K0001RRKHGK K0004RRKHGZ K0001RRKHGK $100 $50 $100 $50 For additional instructions, review CMS Program Memorandum AB-02-168 at www.cms.hhs.gov/Transmittals/downloads/AB02168.pdf. ADVANCE BENEFICIARY NOTICE COMPLETION The Header of the ABN should include the supplier’s company name, address and telephone number. The supplier should also place their company’s logo here if applicable. On the line that indicates patient’s name, the supplier should document the name of the patient and should not substitute the name of an authorized representative. The beneficiary’s Medicare Health Insurance Claim Number (HICN) should be entered on the line stating Medicare number. The following information should be entered in the body of the ABN. Section A In this section (beginning with “We expect that Medicare will not pay for the item (s) or service (s)”— in the “Items or Services” box) specify the health care items or services for which you expect Medicare will deny. A detailed description of the items or services should be provided so the beneficiary fully understands which items may not be paid for by Medicare. In the second box, which is identified as the “Because:” box state in detail the specific reason why Medicare is likely to deny payment for the particular item or service. The reasoning should be clearly understood to the patient. Estimated Cost Line Suppliers may provide the beneficiary with an estimated cost of the items and/or services. Option 1 and Option 2 Boxes The supplier should have the beneficiary select one of the following two boxes: Option 1 (Yes. I want to receive these items and/or services.) Option 2 (No. I have decided not to receive these items or services.) Date and Signature Line The patient, or person acting on his or her behalf, should enter the date of which they signed the ABN in the “Date” blank area. In the “Signature of patient…” blank, the patient, or the person acting on his or her behalf, must sign his or her name. 4 Patient’s Name: Medicare # (HICN): ADVANCE BENEFICIARY NOTICE (ABN) NOTE: You need to make a choice about receiving these health care items or services. We expect that Medicare will not pay for the item(s) or service(s) that are described below. Medicare does not pay for all of your health care costs. Medicare only pays for covered items and services when Medicare rules are met. The fact that Medicare may not pay for a particular item or service does not mean that you should not receive it. There may be a good reason your doctor recommended it. Right now, in your case, Medicare probably will not pay for – Items or Services: Because: The purpose of this form is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you might have to pay for them yourself. Before you make a decision about your options, you should read this entire notice carefully. • Ask us to explain, if you don’t understand why Medicare probably won’t pay. • Ask us how much these items or services will cost you (Estimated Cost: $_________________), in case you have to pay for them yourself or through other insurance. PLEASE CHOOSE ONE OPTION. CHECK ONE BOX. SIGN & DATE YOUR CHOICE. Option 1. YES. I want to receive these items or services. I understand that Medicare will not decide whether to pay unless I receive these items or services. Please submit my claim to Medicare. I understand that you may bill me for items or services and that I may have to pay the bill while Medicare is making its decision. If Medicare does pay, you will refund to me any payments I made to you that are due to me. If Medicare denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand I can appeal Medicare’s decision. Option 2. NO. I have decided not to receive these items or services. I will not receive these items or services. I understand that you will not be able to submit a claim to Medicare and that I will not be able to appeal your opinion that Medicare won’t pay. _____________ _ Date _________________________________________ Signature of patient or person acting on patient’s behalf NOTE: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our offices. If a claim is submitted to Medicare, your health information on this form may be shared with Medicare. Your health information which Medicare sees will be kept confidential by Medicare. OMB Approval No. 0938-0566 Form No. CMS-R-131-G (June 2002) Jurisdiction B DME MAC Supplier Manual Chapter 10: Claim Filing Jurisdiction [JUNE 2007] 10 Claim Filing Jurisdiction CLAIM FILING BASED ON BENEFICIARY ADDRESS Four DME MACs process DMEPOS claims for designated states and territories. National Government Services is the Jurisdiction B DME MAC. National Government Services processes DMEPOS claims for the states of Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin. Unlike other Medicare claims, DMEPOS claim jurisdiction is based on the beneficiary’s address on file with the Social Security Administration. A DMEPOS claim should be sent to the DME MAC jurisdiction for the state in which the beneficiary resides. DISPOSITION OF INCORRECTLY FILED CLAIMS Paper Claims Paper claims filed to the incorrect DME MAC for DMEPOS items will be returned to the supplier unprocessed. The supplier must file the claim to the appropriate DME MAC based on beneficiary residence. Suppliers should review the DME MAC jurisdictions list to determine which DME MAC maintains authority over the claim. Electronic Claims Electronic claims transmitted to the incorrect DME MAC for DMEPOS items will be rejected by the DME MAC. A reject code will indicate the claim should be filed to the appropriate DME MAC. Electronic claims transmitted to the incorrect DME MAC will be forwarded to the appropriate DME MAC based on the beneficiary address. The supplier must have an Electronic Data Interchange (EDI) Enrollment form on file at the DME MAC that is receiving the transferred claim. If the supplier does not have an EDI Enrollment form on file with the DME MAC that is receiving the transferred claim, the claim will reject on the front-end and will not be entered into the Medicare processing system. If a supplier does not have an EDI Enrollment form on file, the supplier should contact the jurisdiction that received the transferred claim to obtain an EDI Enrollment form. Examples A beneficiary resides in Michigan and purchases DME in Ohio. The Ohio supplier sends the claim to the local Ohio carrier. The claim will be returned to the supplier. The supplier must send the claim to the appropriate DME MAC (in this case, Jurisdiction B). If a Minnesota supplier files a paper claim for a beneficiary with a permanent residence in Wyoming to the Jurisdiction B DME MAC, the Jurisdiction B DME MAC will send the claim back to the supplier. The supplier must then send the claim to the appropriate DME MAC (Jurisdiction D). 1 Jurisdiction B DME MAC Supplier Manual Chapter 10: Claim Filing Jurisdiction [JUNE 2007] If a Minnesota supplier files an electronic claim to the Jurisdiction B DME MAC for a beneficiary whose permanent residence is Wyoming, the Jurisdiction B DME MAC will transfer the claim to Jurisdiction D DME MAC. If the Jurisdiction D DME MAC has an EDI Enrollment form on file, the Jurisdiction D DME MAC will accept the claim on the front-end and adjudicate the claim. If the Jurisdiction D DME MAC does not have an EDI Enrollment form on file, the claim will reject on the front-end. The supplier must complete and forward an EDI Enrollment form to the Jurisdiction D DME MAC and resubmit the electronic claim. DURABLE MEDICAL EQUIPMENT MEDICARE ADMINISTRATIVE CONTRACTORS The first of the full and open Medicare administrative contractor (MAC) competitions were held for the durable medical equipment (DME) claims workloads. The Centers for Medicare & Medicaid Services (CMS) decided to start the Medicare Contracting Reform initiative with durable medical equipment Medicare administrative contractors (DME MACs) because the workload of the four current durable medical equipment regional carriers (DMERCs) was stable and the risk of any significant program disruption to the provider and beneficiary communities would be minimal. On January 6, 2006, CMS announced that it had awarded the contracts for the four specialty MACs that will handle administration of Medicare claims for DME. Three of the four DME MACs are operational. Jurisdiction A The Jurisdiction A DME MAC contract was awarded to National Heritage Insurance Company (NHIC). NHIC immediately began transition activity and became fully operational as the DME MAC on July 1, 2006. The states included in DME MAC Jurisdiction A are: Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont. Jurisdiction B The Jurisdiction B DME MAC contract was awarded to National Government Services, Inc., which immediately began transition activity and became fully operational as the DME MAC on July 1, 2006. The states included in DME MAC Jurisdiction B are: Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin. Jurisdiction C The Jurisdiction C DME MAC contract was awarded to CIGNA Government Services, which became fully operational as the DME MAC on June 1, 2007. The states included in Jurisdiction C are: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia and West Virginia. 2 Jurisdiction B DME MAC Supplier Manual Chapter 10: Claim Filing Jurisdiction [JUNE 2007] Jurisdiction D The Jurisdiction D DME MAC contract was awarded to Noridian Administrative Services (NAS). The states included in DME MAC Jurisdiction D are: Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington and Wyoming. On January 24, 2006 CIGNA filed a protest of this award made to NAS and an automatic stay on performance of work was triggered until a decision on the protest could be rendered. On May 4, 2006, CMS received notification that GAO denied CIGNA’s protest of the award to NAS. As a result of this decision, CMS authorized NAS to resume work under Jurisdiction D as of May 8, 2006. As of September 30, 2006, NAS had assumed full responsibility for administering the DME work for Jurisdiction D. Additional DME MAC Contract Options The solicitation for DME MAC contracts also included four options for which offerors were able to submit proposals: the Medicare Electronic Data Interchange System (MEDIS), the Data Center, the National Supplier Clearinghouse (NSC) and Data Analysis and Coding (DAC) (similar to the current SADMERC). Those options were originally awarded on January 6, 2006, to Palmetto. But, because of the protests of the Jurisdiction C DME MAC award and the fact that Jurisdictions A, B, and D have already become operational using nonstandard front-end systems and individual data centers, CMS has decided that the MEDIS and the Data Center are being dropped from award consideration. Decisions with respect to the NSC and DAC are pending. In the interim, Palmetto GBA will be providing those services through their contracts for the NSC and SADMERC. Resources Current information on Medicare Administrative Contracts can be found on the CMS Web site at www.cms.hhs.gov/MedicareContractingReform/08_DurableMedicalEquipmentMedicareAdministrativeCo ntractor.asp. DME MAC JURISDICTIONS The map on the following page identifies the four DME MAC jurisdictions and the states each is contracted to serve. 3 Jurisdiction B DME MAC Supplier Manual Chapter 10: Claim Filing Jurisdiction [JUNE 2007] DME MAC Jurisdictions 4 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] 11 Claim Submission ACCEPTABLE CLAIM FORMATS Durable medical equipment Medicare administrative contractors (DME MACs) accept Medicare claims both on paper using the CMS-1500 claim form and electronically. The CMS-1500 is one of the basic forms prescribed by the Centers for Medicare & Medicaid Services (CMS) for the Medicare Program. It is only accepted from physicians and suppliers that are excluded from the mandatory electronic claims submission requirements set forth in the Administrative Simplification Compliance Act, Public Law 107-0105 (ASCA), and the implementing regulation at 42 CFR 424.32. To accommodate the reporting of the national provider identifier (NPI), the CMS-1500 claim form (version 12-90) was revised in July of 2006. The new CMS-1500 claim form (version 08-05) became effective January 1, 2007. The major difference between the revised CMS-1500 (version 12-90) and the version 08-05 CMS-1500 claim form is the split provider identifier fields. CMS Change Request 5616 announced that beginning July 2, 2007, suppliers who are eligible to submit paper claims must use the CMS-1500 claim form (version 8-05). Claims received on or after July 2, 2007 version 12-90 of the CMS-1500 claim form will be rejected. Note: Acceptance of the CMS-1500 claim form (version 08-05) involves the paper claim form only. Suppliers submitting electronic claims are required to use the Health Insurance Portability and Accountability Act (HIPAA) compliant format. For information on electronic claim submission, please refer to Chapter 12, Electronic Data Interchange, in this manual. CLAIM FILING TIME LIMITS Medicare law prescribes specific time limits within which claims for benefits may be submitted. The terms of the law require that the claim be filed no later than the end of the calendar year following the year in which the service was furnished, except as follows. The time limit on filing claims for services furnished in the last three months of a year is the same as if the services had been furnished in the subsequent year. Therefore, the time limit on filing claims for services furnished in the last three months of the year is December 31 of the second year following the year in which the services were rendered. For example: Note: For services rendered on or before September 30, 2006, the claim filing time limit has expired. For Dates of Service: The Claim Must Be Filed By: October 1, 2004–September 30, 2006 October 1, 2005–September 30, 2007 December 31, 2007 December 31, 2008 1 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] October 1, 2006–September 30, 2008 October 1, 2007–September 30, 2009 December 31, 2009 December 31, 2010 Whenever the last day for timely filing of a claim falls on a Saturday, Sunday, federal nonworkday or legal holiday, the claim will be considered timely if it is filed on the next workday. Claims for services filed outside the time limit will be denied. According to the Omnibus Budget Reconciliation Act (OBRA) of 1989, assigned Medicare claims must be filed within one year from the date of service or the payment will be reduced by 10 percent. Supplier Responsibility for Filing Claims To Medicare OBRA 89 requires a Medicare provider to submit a completed claim within one year when furnishing covered items to a Medicare beneficiary. The provider is relieved of this obligation when furnishing noncovered items, unless the beneficiary requests Medicare payment/determination. If the beneficiary chooses to waive Medicare determination/payment, the supplier is relieved of the responsibility to file claims for covered Medicare items. Should the beneficiary change his/her mind in the future, the supplier would again be responsible for submitting claims for covered items to Medicare. The participating supplier must always accept assignment on a claim and must accept the resulting Medicare allowed amount as full reimbursement for the item(s). A 10 percent reduction in the allowed amount occurs for claims not filed within one year of the service date. The beneficiary is not responsible for this reduction. Participating suppliers are responsible for obtaining all necessary supporting documentation to prove the medical necessity (where applicable), order prior to delivery, as well as any additional information as specified in the medical policies. The nonparticipating supplier has the option to choose—on a claim-by-claim basis—whether to accept assignment on a Medicare claim. If the supplier chooses to accept assignment, the supplier must file a complete claim to Medicare on the beneficiary’s behalf. The 10 percent reduction for claims filed beyond the one-year limitation applies. The supplier must also accept the Medicare allowed amount as the full payment for the item(s) furnished. In this instance, the supplier is responsible for obtaining all documentation to support the medical need of the item (i.e., the physician’s order, a certificate of medical necessity [if applicable] and order prior to delivery, and any additional information as specified in the medical policies). When a nonparticipating supplier chooses not to accept assignment, the supplier must file a claim to Medicare on the patient’s behalf. Either the supplier or the beneficiary can obtain the medical necessity information to support the need of the item(s). Suppliers must ensure the beneficiary understands Medicare may not reimburse if the required information is missing. The supplier may choose to hold the Medicare claim until the beneficiary presents the medical documentation. If the beneficiary refuses to obtain the necessary documentation, the supplier should file the claim, including as much information as possible. 2 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] SIGNATURE ON FILE REQUIREMENTS Medicare requires that suppliers obtain beneficiary authorization before filing claims for any service to the DME MAC. This authorization is called the Assignment of Benefits (AOB) and must be signed by the beneficiary or their authorized representative. The AOB applies only to those particular items listed on the form. The supplier should maintain this one-time payment authorization in the patient’s records. The supplier must indicate “SOF” or “signature on file” in Box 12 on the CMS-1500 claim form when billing Medicare. When a beneficiary is unable to sign because of mental or physical limitations, forms may be signed on their behalf by one of the following representatives: Legal guardian Representative payee—a person designated by the Social Security Administration or other governmental agency to receive an incapable beneficiary’s monthly cash benefits Authorized representative—acts on behalf and in best interest of the beneficiary and is usually a parent, legal guardian of minor, or legal guardian of an adult who has been declared incompetent Designee—any person who can sign and accept the delivery of durable medical equipment (DME) on behalf of the beneficiary Relative Friend Representative of an institution providing care or support Governmental agency providing assistance If the patient is unable to sign, the statement’s signature line must indicate the patient’s name followed by the word “by,” and then the representative’s name, address, relationship to the patient and the reason the patient cannot sign. When an illiterate or physically handicapped beneficiary signs by mark (X), the signature and address of the witness should be entered next to the beneficiary’s mark. This procedure must be implemented by suppliers utilizing paperless (electronic) claim submission. Suppliers must incorporate the following language in a document to be signed by the patient and retained in the supplier’s files. Statement to Permit Payment of Medicare Benefits to Provider, Physicians and Patient Name of Beneficiary HICN I request that payment of authorized Medicare benefits be made either to me or on my behalf for any services furnished me by or in (name of Provider), including physician services. I authorize any holder of medical or other information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits or benefits for related services. 3 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] These records should be easily accessible and available for DME MAC inspection upon request. If the required information is not on the AOB form, then the form will be considered invalid and an overpayment will be requested if payment has been made. Once the above statement is executed, suppliers may enter “signature on file” in the patient’s signature line of the CMS-1500 claim form. Suppliers must complete and promptly submit a claim whenever durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) items are rendered to a Medicare beneficiary—even if assignment is not accepted. On any bills or receipts sent to Medicare patients, the following statement should be included. Do not use this bill for claiming Medicare benefits. A claim has been, or will be, submitted to Medicare on your behalf. If the patient has a Medigap policy, the following statement below must be signed by the patient or their authorized representative to authorize payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in Item 9 of the CMS-1500 claim form and its subdivisions. Date Patient Name Health Insurance Claim Number I request that payment of authorized Medicare benefits be made on my behalf to (SUPPLIER NAME) for any services furnished to me by (SUPPLIER NAME). I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits. Once the above statement is executed, suppliers must indicate on the claim form that a separate Medigap authorization has been obtained by entering “SOF” in Item 13 of the CMS-1500 form. The Medigap assignment on file in the participating provider and/or supplier’s office must be insurerspecific. It may state that the authorization applies to all occasions of service until it is revoked. ORDERING CLAIM FORMS Copies of the current CMS-1500 claim form (version 08/05) may be ordered from the Superintendent of Documents; negatives for the CMS-1500 may be ordered from the U.S. Government Printing Office (GPO). To purchase them from the GPO, call 202-512-1800. With these negatives, a printer may produce copies of the CMS-1500 claim form. They may be altered to overprint a provider’s name address and provider number. 4 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] CMS-1500 Paper Claim Form Single Sheet 2 Part Snap-out 1 Part Continuous 2 Part Continuous 100 100 2500 1400 $13 $15 $72 $59 017-060-00468-1 017-060-00469-0 017-060-00470-3 017-060-00471-1 All of the forms listed above are sensor coded. On any order for 100 packages or more that is shipped to one address, a 25 percent discount can be applied to the prices shown above. For orders of 100,000 copies or more, the Superintendent of Documents can furnish CMS-1500 claim forms preprinted with the practitioner’s name, address, and ID number, or customize the form in certain other ways. For information on this service, contact the GPO Superintendent of Documents at 202-512-2404. Ordering Information Contact the GPO Superintendent of Documents Order Desk between 8:00 a.m. and 4:30 p.m. Eastern Standard Time (ET) at 202-512-1800. Note: Orders must be placed using the SupDocs stock number. CMS-1500 Negatives Negatives for the CMS-1500 claim form and a specification package may be purchased. To purchase a negative, make a check payable to “The Public Printer” and mail it along with the order to the following address: Asst. Supt. of Dept. Acct. Rep. Div. U.S. Government Printing Office, Room C-830 Washington, District of Columbia 20401 Do not submit a purchase order, voucher or similar form for purchase, as this office can only process payment by check or money order. Shipment will be made approximately five business days after receipt of the order. For additional information, call 202-512-1257. CMS-1500 HINTS AND TIPS Four-Digit Year All dates should be written as a four-digit year, for example: 06/01/2001. Date-Spanning When billing for items in which date spanning is recommended or required, the delivery date may be listed in the “From” field and the “To” field should indicate the date for which the supplies are expected to last. 5 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Multiple Forms When a claim contains more than six items it should be continued on a second CMS-1500 form. Write “continued” in Item 28 of all but the last form, and enter the cumulative total in Item 28 of the last form. Other than Item 28, the additional forms should be completed in full. Check the Completed Form Carefully Watch for the following items. These are the most frequent reasons for claim rejection. Incorrect supplier numbers − National provider identifier (NPI) (Item 33a) − NSC supplier number (Item 33b) Missing or incorrect signatures (Items 12 and 31) Diagnosis in Box 24e instead of Item 21 Missing modifiers on capped rental, inexpensive or other routinely purchased DME items (IRP) Item 11 must not be left blank; if not applicable, write “None” in this section NEW REVISED CMS-1500 FORM (VERSION 08-05) The new revised CMS-1500 claim form, version 08-05, became effective January 1, 2007, but was not mandated for supplier use until July 1, 2007. The CMS MLN Matters article MM5616 provides additional details and instructions on the use of the new CMS-1500 claim form (version 08-05) and the termination of the transition period to accept the previous CMS-1500 claim form (version 12-90). A change log that identifies the various changes made to the new revised CMS-1500 claim form (version 08-05) is available and can be viewed on the National Uniform Claim Committee (NUBC) Web site at www.nucc.org/images/stories/PDF/change_log.pdf. A sample CMS-1500 claim form (version 08-05) and form completion instructions are included on the following pages. The new CMS-1500 form can also be located on the CMS Web site at www.cms.hhs.gov/cmsforms/downloads/CMS1500805.pdf. 6 CARRIER 1500 HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA MEDICARE MEDICAID (Medicare #) (Medicaid #) TRICARE CHAMPUS (Sponsor ’s SSN) GROUP HEALTH PLAN (SSN or ID) CHAMPVA (Member ID#) FECA BLK LUNG (SSN) 3. PATIENT’S BIRTH DATE MM DD YY 2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 5. PATIENT’S ADDRESS (No., Street) OT HER 4. INSURED ’S NAME (Last Name, First Name, Middle Initial) SEX M F 7. INSURED ’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED Self CITY STATE STATE CITY Married Other (Include Area Code) TELEPHONE ( Other 8. PATIENT STATUS Single ZIP CODE Child Spouse (For Program in Item 1) (ID) ZIP CODE ) Employed Full-Time Student TELEPHONE (Include Area Code) ( Part-Time Student ) 9. OTHER INSURED ’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH MM DD YY NO YES b. OTHER INSURED’S DATE OF BIRTH MM DD YY b. AUTO ACCIDENT? SEX PLACE (State) c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? b. EMPLOYER’S NAME OR SCHOOL NAME c. INSURANCE PLAN NAME OR PROGRAM NAME NO YES d. INSURANCE PLAN NAME OR PROGRAM NAME d. IS THERE ANOTHER HEALTH BENEFIT PLAN? 10d. RESERVED FOR LOCAL USE YES READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. SIGNED 14. DATE OF CURRENT: MM DD YY 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE NO If yes , return to and complete item 9 a-d. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. DATE ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP) SIGNED 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. MM DD YY GIVE FIRST DATE 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD FROM TO YY 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD FROM TO YY 17b. NPI 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? YES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) 1. F NO YES F M SEX M PATIENT AND INSURED INFORMATION 1. PICA 1a. INSURED ’S I.D. NUMBER $ CHARGES NO 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 3. 2. 24. A. MM DATE(S) OF SERVICE From To DD YY MM DD YY B. PLACE OF SERVICE C. EMG 4. D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER E. DIAGNOSIS POINTER F. H. G. EPSDT Family Plan DAYS OR UNITS $ CHARGES 1 I. J. RENDERING PROVIDER ID. # ID. QUAL. NPI 2 NPI 3 NPI 4 NPI 5 NPI 6 PHYSICIAN OR SUPPLIER INFORMATION 23. PRIOR AUTHORIZATION NUMBER NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 27. ACCEPT ASSIGNMENT? 26. PATIENT’S ACCOUNT NO. ( For govt. claims, see back ) YES 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) SIGNED DATE 32. SERVICE FACILITY LOCATION INFORMATION a. NUCC Instruction Manual available at: www.nucc.org NPI b. NO 28. TOTAL CHARGE $ 29. AMOUNT PAID $ 33. BILLING PROVIDER INFO & PH # a. 30. BALANCE DUE $ NPI ( ) b. APPROVED OMB-0938-0999 FORM CMS-1500 (08/05) BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. REFERS TO GOVERNMENT PROGRAMS ONLY MEDICARE AND CHAMPUS PAYMENTS: A patient’s signature requests that payment be made and authorizes release of any information necessary to process the claim and certifies that the information provided in Blocks 1 through 12 is true, accurate and complete. In the case of a M edicare claim, the patient’s signature authorizes any entity to release to Medicare medical and nonmedical information, including employment status, and whether the person has employer group health insurance, liability, no-fault, worker’s compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made. See 42 CFR 411.24(a). If item 9 is completed, the patient’s signature authorizes release of the information to the health plan or agency shown. In Medicare assigned or CHAMPUS participation cases, the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge, and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted. CHAMPUS is not a health insurance program but makes payment for health benefits provided through certain affiliations with the Uniformed Services. Information on the patient ’s sponsor should be provided in those items captioned in “Insured ”; i.e., items 1a, 4, 6, 7, 9, and 11. BLACK LUNG AND FECA CLAIMS The provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA instructions regarding required procedure and diagnosis coding systems. SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK LUNG) I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished incident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS regulations. For services to be considered as “incident” to a physician’s professional service, 1) they must be rendered under the physician’s immediate personal supervision by his/her employee, 2) they must be an integral, although incidental part of a covered physician’s service, 3) they must be of kinds commonly furnished in physician’s offices, and 4) the services of nonphysicians must be included on the physician’s bills. For CHAMPUS claims, I further certify that I (or any employee) who rendered services am not an active duty member of the Uniformed Services or a civilian employee of the United States Government or a contract employee of the United States Government, either civilian or military (refer to 5 USC 5536). For Black-Lung claims, I further certify that the services performed were for a Black Lung-related disorder. No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations (42 CFR 424.32). NOTICE: Any one who misrepresents or falsifies essential information to receive payment from Federal funds requested by this form may upon conviction be subject to fine and imprisonment under applicable Federal laws. NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, CHAMPUS, FECA, AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENT) We are authorized by CMS, CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare, CHAMPUS, FECA, and Black Lung programs. Authority to collect information is in section 205(a), 1862, 1872 and 1874 of the Social Security Act as amended, 42 CFR 411.24(a) and 424.5(a) (6), and 44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086; 5 USC 8101 et seq; and 30 USC 901 et seq; 38 USC 613; E.O. 9397. The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide if the services and supplies you received are covered by these programs and to insure that proper payment is made. The information may also be given to other providers of services, carriers, intermediaries, medical review boards, health plans , and other organizations or Federal agencies, for the effective administration of Federal provisions that require other third parties payers to pay primary to Federal program, and as otherwise necessary to administer these programs. For example, it may be necessary to disclose information about the benefits you have used to a hospital or doctor. Additional disclosures are made through routine uses for information contained in systems of records. FOR MEDICARE CLAIMS: See the notice modifying system No. 09-70-0501, titled, ‘Carrier Medicare Claims Record,’ published in the Federal Register, Vol. 55 No. 177, page 37549, Wed. Sept. 12, 1990, or as updated and republished. FOR OWCP CLAIMS: Department of Labor, Privacy Act of 1974, “Republication of Notice of Systems of Records,” Federal Register Vol. 55 No. 40, Wed Feb. 28, 1990, See ESA-5, ESA-6, ESA-12, ESA-13, ESA-30, or as updated and republished. FOR CHAMPUS CLAIMS: PRINCIPLE PURPOSE(S): To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment of eligibility and determination that the services/supplies received are authorized by law. ROUTINE USE(S): Information from claims and related documents may be given to the Dept. of Veterans Affairs, the Dept. of Health and Human Services and/or the Dept. of Transportation consistent with their statutory administrative responsibilities under CHAMPUS/CHAMPVA; to the Dept. of Justice for representation of the Secretary of Defense in civil actions; to the Internal Revenue Service, private collection agencies, and consumer reporting agencies in connection with recoupment claims; and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be made to other federal, state, local, foreign government agencies, private business entities, and individual providers of care, on matters relating to entitlement, claims adjudication, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil and criminal litigation related to the operation of CHAMPUS. DISCLOSURES: Voluntary; however, failure to provide information will result in delay in payment or may result in denial of claim. With the one exception discussed below, there are no penalties under these programs for refusing to supply information. However, failure to furnish information regarding the medical services rendered or the amount charged would prevent payment of claims under these programs. Failure to furnish any other information, such as name or claim number, would delay payment of the claim. Failure to provide medical information under FECA could be deemed an obstruction. It is mandatory that you tell us if you know that another party is responsible for paying for your treatment. Section 1128B of the Social Security Act and 31 USC 38013812 provide penalties for withholding this information. You should be aware that P.L. 100-503, the “Computer Matching and Privacy Protection Act of 1988,” permits the government to verify information by way of computer matches. MEDICAID PAYMENTS (PROVIDER CERTIFICATION) I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State ’s Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or Dept. of Health and Human Services may request. I further agree to accept, as payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception of authorized deductible, coinsurance, co-payment or similar cost-sharing charge. SIGNATURE OF PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to the health of this patient and were personally furnished by me or my employee under my personal direction. NOTICE: This is to certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0999. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information co llection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. This address is for comments and/or suggestions only. DO NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS. Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Item # 1 Description Type of claim Cause Reject Yes 1a Insured’s ID Yes 2 Patient’s name Yes 3 4 Patient’s birthdate/sex Insured’s name Yes 5 Patient’s address 6 7 Patient relationship to insured Insured’s address 8 Patient status 9 Other insured’s name Special Instructions Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed, check the Medicare box. Enter the patient’s Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer. This is a required field. Enter the patient’s name, first name and middle initial, if any, as shown on the patient’s Medicare card. This is a required field. Enter patient’s eight-digit birth date (MM/DD/CCYY) and sex. If there is insurance primary to Medicare, either through the patient’s or spouse’s employment or any other source, list the name of the insured here. When the insured and the patient are the same enter “Same.” If Medicare is primary, leave blank. Enter the patient’s mailing address and telephone number. On the first line, enter the street address; the second line, the city and state; the third line, the zip code and phone number. If the beneficiary has a representative payee, then the representative payee’s address is listed in Item 4. The beneficiary’s actual residence is then entered in Item 32. This information is required in case the representative payee is located in a different state from the beneficiary. Check appropriate box for patient’s relationship to insured when Item 4 is completed. Enter the insured’s address and telephone number. When the address is the same as the patient’s, enter the word “Same.” Complete this item only when Items 4 and 11 are completed. Check the appropriate box for the patient’s marital status and whether employed or a student. Enter the last name, first name and middle initial of the enrollee in a Medigap policy, if it is different from that shown in Item 2; otherwise, enter the word “Same.” If no Medigap benefits are assigned, leave blank. This field may be used in the future for supplemental insurance plans. Only participating physicians and suppliers are to complete Item 9 and its subdivisions and only when the beneficiary wishes to assign his/her benefits under a Medigap policy to the participating physician or supplier. Participating physicians and suppliers must enter information required in Item 9 and its subdivisions if requested by the beneficiary. Participating physician’s/suppliers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients. A claim for which a beneficiary elects to assign his/her benefits under a Medigap policy to a participating physician/supplier is called a mandated Medigap transfer. Medigap: A Medigap policy meets the statutory definition of a “Medicare supplemental policy” contained in both Sections 1882(g)(1) of Title XVIIII of the Social Security Act and the definition contained in the NAIC Model Regulation which is incorporated by reference to the statute. It is a health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits. It fills in some of the “gaps” in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the applicability of deductibles, coinsurance amounts, or other limitations imposed by Medicare. It does not include limited benefit coverage available to Medicare beneficiaries such as “specified disease” or “hospital indemnity” coverage. Also, it explicitly excludes a policy or plan offered by an employer to employees, or former employees, as well as that offered by a labor organization to members or former members. 9 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Item # Description 9a Other insured’s policy or group number 9b Other insured’s date of birth Employer’s name or school name 9c 9d Cause Reject Yes Insurance plan name or program name 10 Is patient’s condition related to: 10d Reserved for local use 11 Insured’s policy, group or FECA number Yes Special Instructions Do not list other supplemental coverage in Item 9 and its subdivisions at the time a Medicare claim is filed. Other supplemental claims are forwarded automatically to the private insurer if the private insurer contracts with the carrier to send Medicare claim information electronically. If there is no such contract, the beneficiary must file his/her own supplemental claim. Enter the policy and/or group number of the Medigap insured preceded by Medigap. Note: Item 9d must be completed if you enter a policy and/or group number in Item 9a. Enter the Medigap insured’s eight-digit birth date (MM/DD/CCYY) and sex. Leave blank if a Medigap PayerID is entered in Item 9d. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter postal code, and zip code copied from the Medigap insured’s Medigap identification card. For example: 1257 Anywhere Street Baltimore, MD 21204 is shown as “1257 Anywhere St MD 21204.” Enter the five-digit COBA Medigap claim base identifier. If no identifier exists, then enter the Medigap insurance program or plan name. Note: The identifiers will range from 55000–59999. If you are a participating provider of service or supplier and the beneficiary wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, all of the information in Items 9, 9a, 9b, and 9d must be complete and accurate. Otherwise, the Medicare carrier cannot forward the claim information to Medigap insurer. Providers/suppliers may reference a list of assigned COBA Medigap claim-based identifiers for Medicare billing at www.cms.hhs.gov/COBAgreement/Downloads/Medigap%20Claimbased%20COBA%20IDs%20for%20Billing%20Purpose.pdf. Note: This list is updated weekly. Check “yes” or “no” to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in Item 24. Enter the state postal code. Any item checked “yes” indicates there may be other insurance primary to Medicare. Identify primary insurance information in Item 11. Use this item exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient’s Medicaid number preceded by MCD. This item must be completed. By completing this item, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer. If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to Items 11a through 11c. Note: Enter the appropriate information in Item 11c if insurance primary to Medicare is indicated in Item 11. If there is no insurance primary to Medicare, enter the word “None” and proceed to Item 12. If there has been a change in the insured’s insurance status due to their employment status, e.g., retired, enter the word “None” and proceed to Item 11b. Insurance primary to Medicare circumstances under which Medicare payment may be secondary to other insurance include: group health plan coverage, Working Aged, Disability (large group health plan [LGHP]), End-Stage Renal Disease (ESRD), No-fault, work-related illness/injury Workers’ Compensation, Black Lung and Veterans Benefits. Items 4, 6, and 7 must also be completed. 10 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Item # Description 11a 11b Insured’s date of birth Employer’s name or school name 11c Insurance plan name or program name 11d Is there another health benefit plan Patient’s or authorized person’s signature 12 Cause Reject Yes Special Instructions Note: For a paper claim to be considered for Medicare Secondary Payer benefits, a copy of the primary payer’s Explanation of Benefits (EOB) notice must be forwarded along with the claim form. Enter the insured’s birth date and sex if different from Item 3. Enter the employer’s name if applicable. If there is a change in the insured’s insurance status, e.g. retired, enter the retirement date preceded by the word “Retired.” Enter the nine-digit PayerID number of the primary insurer. If no PayerID number exists, then enter the complete primary payer’s program or plan name. If the primary payer’s EOB does not contain the claims processing address, record the primary payer’s claims processing address directly on the EOB. This is required if there is insurance primary to Medicare that is indicated in Item 11. Leave blank. Not required by Medicare. The patient or authorized representative must sign and date this item unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician or supplier file in accordance with Sections 3047.1–3047.3. If the patient is physically or mentally unable to sign, a representative specified in Section 3008 may sign on the patient’s behalf. In this event, the statement’s signature line must indicate the patient’s name followed by “by” the representative’s name, address, relationship to the patient and the reason the patient cannot sign. The authorization is effective indefinitely unless patient or the patient’s representative revokes this arrangement. Note: This can be a “Signature on File” and/or a computer generated signature. The patient’s signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim. 13 Insured’s or authorized person’s signature 14 Date of current illness 15 If patient has had same or similar illness, give first date Date patient unable to work in current occupation 16 Signature by Mark: When an illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark. The signature in this item authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in Item 9 and its subdivisions. The patient or his/her authorized representative signs this item, or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier’s office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked. Note: This can be a “Signature on File” and/or a computer generated signature. Enter the date of current illness, injury, or pregnancy. For chiropractic services, enter the date of the initiation of the course of treatment and enter the X-ray date (MM/DD/YY) in Item 19. Leave blank. Not required by Medicare. Enter dates patient is employed and unable to work in current occupation. (An entry in this field may indicate employment related insurance coverage.) 11 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Item # 17 Description Name of referring physician or other source Cause Reject Yes Special Instructions Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. The term “physician” when used within the meaning of Section 1861(r) of the Social Security Act (the Act) and used in connection with performing any function or action refers to: 1) A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the state in which he/she performs such function or action; 2) A doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the state in which he/she performs such functions and who is acting within the scope of his/her license when performing such functions; 3) A doctor of podiatric medicine for purposes of Sections (k), (m), (p)(1) and (s) and Sections 1814(a), 1832(a)(2)(F)(ii) and 1835 of the Act, but only with respect to functions which he/she is legally authorized to perform as such by the state in which he/she performs them; 4) A doctor of optometry, but only with respect to the provision of items or services described in Section 1861(s) of the Act which he/she is legally authorized to perform as a doctor of optometry by the state in which he/she performs them; or 5) A chiropractor who is licensed as such by a state (or in a state which does not license chiropractors as such), and is legally authorized to perform the services of a chiropractor in the jurisdiction in which he/she performs such services, and who meets uniform minimum standards specified by the Secretary, but only for purposes of Sections 1861(s)(1) and 1861(s)(2)(A) of the Act, and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation). For the purposes of Section 1862(a)(4) of the Act and subject to the limitations and conditions provided above, chiropractor includes a doctor of one of the arts specified in the statute and legally authorized to practice such art in the country in which the inpatient hospital services (referred to in Section 1862[a][4] of the Act) are furnished. Referring physician is a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program. Ordering physician is a physician or, when appropriate, a nonphysician practitioner who orders nonphysician services for the patient. Reference the CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 for nonphysician practitioner rules. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician’s or nonphysician practitioner’s service. The ordering/referring requirement became effective January 1, 1992, and is required by Section 1833(q) of the Act. All claims for Medicare covered services and items that are the result of a physician's order or referral shall include the ordering/referring physician's name. See Items 17a and 17b below for further guidance on reporting the referring/ordering provider’s UPIN and/or NPI. The following services/situations require the submission of the referring/ordering provider information: Medicare covered services and items that are the result of a physician’s order or referral 12 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Item # Description 17a Non NPI Cause Reject Special Instructions Parenteral and enteral nutrition Immunosuppressive drug claims Hepatitis B claims Diagnostic laboratory services Diagnostic radiology services Portable x-ray services Consultative services Durable medical equipment When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests) When a service is incident to the service of a physician or nonphysician practitioner, the name of the physician or nonphysician practitioner who performs the initial service and orders the nonphysician service must appear in Item 17 When a physician extender or other limited licensed practitioner refers a patient for consultative service, submit the name of the physician who is supervising the limited licensed practitioner Enter the ID qualifier 1G, followed by the CMS assigned UPIN of the referring/ordering physician listed in Item 17. The UPIN may be reported on the CMS-1500 claim form until May 22, 2007, and must be reported if an NPI is not available. Note: Field 17a and/or 17b is required when a service was ordered or referred by a physician. Effective May 23, 2008, and later, 17a is not to be reported but 17b must be reported when a service was ordered or referred by a physician. 17b 18 19 NPI of referring physician Hospitalization dates related to current services Reserved for local use When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring physician. All physicians who order or refer Medicare beneficiaries or services must report either an NPI or UPIN or both prior to May 23, 2007. After that date, an NPI (but not a UPIN) must be reported even though they may never bill Medicare directly. A physician who has not been assigned a UPIN shall contact the Medicare carrier. Refer to the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 14, Section 14.6 for additional information regarding UPINs. Enter the NPI of the referring/ordering physician listed in Item 17 as soon as it is available. The NPI may be reported on the CMS-1500 claim form (version 08-05) as early as January 1, 2007. Note: Field 17a and/or 17b is required when a service was ordered or referred by a physician. Effective May 23, 2008, and later, 17a is not to be reported but 17b must be reported when a service was ordered or referred by a physician. Complete this item when a medical service is furnished as a result of, or subsequent to, a related hospitalization. Enter the date the patient was last seen and the NPI of his/her attending physician when an independent physical or occupational therapist, or physician providing routine foot care submits claims. For physical and occupational therapists, entering this information certifies that the required physician certification (or recertification) is being kept on file (see 2206.1). Enter the x-ray for chiropractor services. By entering an x-ray date and the initiation date for course of chiropractic treatment in Item 14, you are certifying that all the relevant information requirements (including level of subluxation) of the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 are on file along with the appropriate x-ray and are all available for carrier review. 13 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Item # Description Cause Reject Special Instructions Enter the drug’s name and dosage when submitting a claim for Not Otherwise Classified (NOC) drugs. Enter a concise description of an “unlisted procedure code” if one can be given within the confines of this box. Otherwise an attachment must be submitted with the claim. Enter all applicable modifiers when modifier 99 (multiple modifiers) is entered in Item 24d. If modifier 99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing modifier 99 should be listed as follows: 1=(mod), where the number 1 represents the line item and “mod” represents all modifiers applicable to the referenced line item. Enter the statement “Homebound” when an independent lab renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. (See CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health Services,” and CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 16, “Laboratory Services from Independent labs, Physicians and Providers” and CMS IOM Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, “Definitions,” respectively for the definition of “homebound” and a more complete definition of a medically necessary laboratory service to a homebound or an institutional patient.) Enter the statement, “Patient refuses to assign benefits” when the beneficiary absolutely refuses to assign benefits to a participating provider. In this case, no payment may be made on the claim. Enter the statement, “Testing for hearing aid” when submitting claims to obtain intentional denials when other payers are involved. (When dental exams are billed, enter the specific surgery for which the exam is being performed.) Enter the specific name and dosage amount when low osmolar contrast material is billed but only if HCPCS codes do not cover them. 20 Outside lab Enter the assumed and/or relinquished date for a global surgery claim when providers share post-operative care. Enter the statement, “Attending physician, not hospice employee” when a physician renders services to a hospice patient but the hospice providing the patient’s care (in which the patient resides) does not employ the attending physician. Complete this item when billing for diagnostic tests subject to purchase price limitations. Enter the purchase price under charges if the “yes” is checked. A “yes” check indicates that an entity other than the entity billing for the service performed the diagnostic test. A “no” check indicates that no purchased tests are included on the claim. When “yes” is annotated, Item 32 must be completed. When billing for multiple purchased diagnostic tests, each test must be submitted on a separate claim form. Multiple purchased tests may be submitted on the ASC X12 837 electronic format as long as appropriate line level information is submitted when services are rendered at different service facility locations. Note: This is a required field when billing for diagnostic tests subject to purchase price limitations. 14 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Item # 21 Description Diagnosis or nature of illness or injury 22 23 Medicaid resubmission Prior authorization number Cause Reject Special Instructions Enter the patient’s diagnostic/condition. All physician specialties must use an ICD-9-CM code number and code to the highest level of specificity for the date of service. Enter up to four codes in priority order (primary, secondary condition). An independent laboratory must enter a diagnosis only for limited coverage procedures. All narrative diagnosis for nonphysician specialties must be submitted on an attachment. Leave blank. Not required by Medicare. Enter the Quality Improvement Organization (QIO) prior authorization number for those procedures requiring QIO prior approval. Enter the Investigational Device Exemption (IDE) number when an investigational device is used in a FDA-approved clinical trial. Post Market Approval number should also be placed here when applicable. For physicians performing care plan oversight services, enter the 6-digit Medicare provider number of the home health agency (HHA), or hospice when CPT code G0181 (home health), or G0182 (hospice) is billed. Enter the 10-digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratory services billed by an entity performing CLIA covered procedures. 24a Dates of service Yes 24b Place of service Yes Note: Item 23 can contain only one condition. Any additional conditions should be reported on a separate CMS-1500 form. Enter the month, day and year for each procedure, service or supply. When “from” and “to” dates are shown for a series of identical services, enter the number of days or units in column G. This is a required field. Return as unprocessable if a date of service extends more than one day and a valid “to” date is not present. Enter the appropriate place of service code(s) from the list provided. Identify the location, using a place of service code for each item used or service performed. Note: When a service is rendered to a hospital inpatient, use the “inpatient hospital” code. (Refer below to Place of Service Codes table.) Place of Service Codes Code 00–02 03 04 Title Unassigned School Homeless Shelter 05 Indian Health Service Freestanding Facility 06 Indian Health Service Provider-Based Facility Definition A facility whose primary purpose is education A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters). Please note that for the purposes of receiving durable medical equipment (DME), a homeless shelter is considered the beneficiary’s home. A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to American Indians and Alaska natives who do not require hospitalization. Medicare does not currently use the POS code designated for this setting. Claims submitted with this code will be returned as unprocessable. A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients. Medicare does not currently use the POS code designated for this setting. Claims submitted with this code will be 15 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Code Title Definition returned as unprocessable. 07 Tribal 638 Freestanding Facility 08 Tribal 638 ProviderBased Facility 09 Prison—Correction Facility A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members who do not require hospitalization. Medicare does not currently use the POS code designated for this setting. Claims submitted with this code will be returned as unprocessable. A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members admitted as inpatients or outpatients. Medicare does not currently use the POS code designated for this setting. Claims submitted with this code will be returned as unprocessable. A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either federal, state, or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders. (Effective 07/01/06) 10 11 Unassigned Office 12 Patient’s Home 13 Assisted Living Facility 14 Group Home 15 Mobile Unit 16 Temporary Lodging 17–19 20 Unassigned Urgent Care Facility 21 Inpatient Hospital 22 Outpatient Hospital 23 25 Emergency Room– Hospital Ambulatory Surgical Center Birthing Center 26 Military Treatment 24 Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. Location, other than a hospital or other facility, where the patient receives care in a private residence. Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, seven days a week, with the capacity to deliver or arrange for services including some health care and other services. Congregate residential foster care setting for children and adolescents in state custody that provides some social, health care, and educational support services and that promotes rehabilitation and reintegration of residents into the community. A facility/unit that moves from place to place equipped to provide preventive, screening, diagnostic, and/or treatment services. A short term accommodation such as a hotel, camp ground, hostel, cruise ship, or resort where the patient receives care, and which is not identified by any other POS code. (Effective 04/01/08) Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention. A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. A portion of a hospital that provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided. A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis. A facility, other than a hospital’s maternity facilities or a physician’s office, which provides a setting for labor, delivery, and immediate postpartum care, as well as immediate care of newborn infants. A medical facility operated by one or more of the Uniformed Services. 16 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Code Title Facility 27–30 31 Unassigned Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 35–40 41 Unassigned Ambulance–Land 42 Ambulance–Air or Water Unassigned Independent Clinic 43–48 49 50 Federally Qualified Health Center 51 Inpatient Psychiatric Facility 52 Psychiatric Facility– Partial Hospitalization 53 Community Mental Health Center (CMHC) 54 55 56 Intermediate Care Facility/Mentally Retarded Residential Substance Abuse Treatment Facility Psychiatric Residential Treatment Center Definition Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF). A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services, but does not provide the level of care or treatment available in a hospital. A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals. A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component. A facility other than a patient's home in which palliative and supportive care for terminally ill patients and their families are provided. A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured. An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured. A location, not part of a hospital and not described by any other POS code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. A facility located in a medically under-served area that provides Medicare beneficiaries preventive, primary medical care under the general direction of a physician. A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician. A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility. A facility that provides the following services: Outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC’s mental health services area who have been discharged from inpatient treatment at a mental health facility 24-hour-a-day emergency care services Day treatment, other partial hospitalization services, or psychosocial rehabilitation services Screening for patients being considered for admission to state mental health facilities to determine the appropriateness of such admission, and Consultation and education services A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals, but does not provide the level of care or treatment available in a hospital or SNF. A facility that provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing and room and board. A facility or distinct part of a facility for psychiatric care that provides a total 24-hour therapeutically planned and professionally staffed group 17 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Code Title Definition living and learning environment. 57 Non-residential Substance Abuse Treatment Facility A location that provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing. 58–59 60 Unassigned Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 63–64 65 Unassigned End-Stage Renal Disease Treatment Facility Unassigned State or Local Public Health Clinic 66–70 71 72 Rural Health Clinic 73–80 81 Unassigned Independent Laboratory Unassigned Other Place of Service 82–98 99 Item # 24c 24d 24e Description EMG Procedures, services or supplies Diagnosis pointer Cause Reject Yes A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting. A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services. A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services. A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis. A facility maintained by either state or local health departments that provides ambulatory primary medical care under the general direction of a physician. A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician. A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician’s office. Other place of service not identified above. Special Instructions Leave blank. Medicare providers are not required to complete this box. Enter the procedures, services or supplies using the Healthcare Common Procedure Coding System (HCPCS). When applicable, show HCPCS modifiers with the HCPCS code. Enter the specific procedure code without a narrative description. However, when reporting an “unlisted procedure code” or a “not otherwise classified” (NOC) code, include a narrative description in Item 19 if a coherent description can be given within the confines of that box. Otherwise, an attachment must be submitted with the claim. This is a required field. Return as unprocessable if an “unlisted procedure code” or a NOC code is indicated in Item 24d, but an accompanying narrative is not present in Item 19 or on an attachment. Enter the diagnosis code or reference number as shown in Item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line item. When multiple services are performed, enter the primary reference number for each service: either a 1, or a 2, or a 3 or a 4. If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), you must reference only one of the diagnosis in Item 21. 18 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Item # 24f Description Charges Cause Reject Yes 24g Days or units Yes Special Instructions Enter the charge for each listed service. Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes or oxygen volume. If only one service is performed, the numeral “1” must be entered. Some services require that the actual number or quantity billed be clearly indicated on the claim form (e.g., multiple ostomy or urinary supplies, medication dosages or allergy testing procedure). When multiple services are provided, enter the actual number provided. For anesthesia, show the elapsed time (minutes) in Item 24g. Convert hours into minutes and enter the total minutes required for this procedure. Suppliers must furnish the units of oxygen contents except for concentrators and initial rental claims for gas and liquid oxygen systems. Rounding of oxygen is as follows: 24h 24i 24j EPSDT ID Qualifier (08/05) Rendering provider’s PIN (08/05) 24k Reserved for local use 25 Federal Tax I.D. number For stationary gas system rentals, suppliers must indicate oxygen contents in unit multiples of 50 cubic feet in Item 24g, rounded to the nearest increment of 50. For example, if 73 cubic feet of oxygen were delivered during the rental month, the unit entry “01” indicating the nearest 50 cubic foot increment is entered in Item 24g. For stationary liquid systems, units of contents must be specified in multiples of 10 pounds of liquid contents delivered, rounded to the nearest 10 pound increment. For example, if 63 pounds of liquid oxygen were delivered during the applicable rental month billed, the unit entry “06” is entered in Item 24g. For units of portable contents only (i.e., no stationary gas or liquid system used) round to the nearest cubic feet or one liquid pound, respectively. Leave blank. Not required by Medicare. Enter the ID qualifier 1C in the shaded portion. Prior to May 23, 2007, enter the rendering provider’s PIN in the shaded portion. In the case of a service provided incident to the service of a physician or nonphysician practitioner, when the person who ordered the service is not supervising, enter the PIN of the supervisor in the shaded portion. Effective May 23, 2007 and later, do not use the shaded portion. As of January 1, 2007, enter the rendering provider’s NPI number in the lower portion. In the case of a service provided incident to the service of a physician or nonphysician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the lower portion. Enter the PIN (the NPI will be used when implemented) of the performing provider of service/supplier if the provider is a member of a group practice. When several different providers of service or suppliers within a group are billing on the same CMS-1500 form, show the individual PIN (or NPI when implemented) in the corresponding line item. In the case of a service provided incident to the service of a physician or nonphysician practitioner, when the person who ordered the service is not supervising, enter the PIN (or NPI when implemented) of the supervisor in Item 24K. Enter the provider of service or supplier Federal Tax ID (Employer Identification Number or Social Security Number) and check the appropriate check box. Medicare providers are not required to complete this item for crossover purposes since the Medicare contractor will 19 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Item # Description 26 Patient’s account number 27 Accept assignment Cause Reject Yes Special Instructions retrieve the tax identification information from their internal provider file for inclusion on the COB outbound claim. However, tax identification information is used in the determination of accurate National Provider Identifier reimbursement. Reimbursement of claims submitted without tax identification information will/may be delayed Enter the patient’s account number assigned by the provider of service’s or supplier’s accounting system. This field is optional to assist you in patient identification. As a service, any account numbers entered here will be returned to you. Check the appropriate box to indicate whether the provider of service or supplier accepts assignment of Medicare benefits. If Medigap is indicated in Item 9 and Medigap payment authorization is given in Item 13, the provider of service or supplier must also be a Medicare participating provider of service or supplier and must accept assignment of Medicare benefits for all covered charges for all patients. Note: The following providers of service/suppliers and claims can only be paid on an assignment basis: Physician services to individuals dually entitled to Medicaid and Medicare Clinical diagnostic laboratory services “Participating” physician/supplier services Services of physician assistants, nurse practitioners, clinical nurse specialist, nurse midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers Ambulatory surgical center (ASC) services for covered ASC procedures and home dialysis supplies and equipment paid under Method II Ambulance services Drugs and biologicals, and Simplified billing roster for influenza virus vaccine and pneumococcal vaccine Enter total charges for all services (i.e., total of all charges in Item 24f). Enter the total amount the patient paid on the covered services only. Leave blank. Not required by Medicare. Enter the signature of the provider of service or supplier, or his/her representative, and the date the form was signed. 28 29 30 31 32 Total charge Amount paid Balance due Signature of supplier Name and address of facility where services were rendered Yes NR Yes Note: This is a required field. However, the claim can be processed if the following is true. If a physician, supplier, or authorized person’s signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signature field has “Signature on File” and/or a computer generated signature. Enter the name and address, and zip code of the facility if the services were furnished in a hospital, clinic, laboratory, or facility other than the patient’s home or physician’s office. Effective for claims received on or after April 1, 2004, the name, address, and zip code of the service location for all services other than those furnished in place of service home (code 12). Effective for claims received on or after April 1, 2004, on the CMS-1500 claim form, only one name, address and zip code may be entered in the block. If additional entries are needed, separate claim forms shall be submitted. Effective for claims with dates of service on or after October 1, 2007, the name, address, and nine-digit zip code of the service location for services paid under the Medicare physician fee schedule and anesthesia services, other than those furnished in place of service home (12), and any other places of service contractors treat as home, must be entered 20 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Item # Description Cause Reject Special Instructions according to Chapter 1, Sections 10.1.1 and 10.1.1.1 of the CMS IOM Publication 100-04, Medicare Claims Processing Manual. Effective for claims with dates of service on or after October 1, 2007, for claims received that require a nine-digit zip code with a four-digit extension, a four-digit extension that matches one of the zip 9 file or a four-digit extension that can be verified according to Chapter 1, Sections 10.1.1 and 10.1.1.1 of the CMS IOM Publication 100-04, Medicare Claims Processing Manual must be entered on the claim. Providers of service (namely physicians) shall identify the supplier’s name, address, zip code and PIN when billing for purchased diagnostic tests. When more than one supplier is used, a separate CMS-1500 claim form should be used to bill for each supplier. For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States. These claims will not include a valid zip code. When a claim is received for these services on a beneficiary submitted CMS-1490S form, before the claim is entered in the system, it should be determined if it is a foreign claim. If it is a foreign claim, follow the instructions in Chapter 1 for disposition of the claim. The carrier processing the foreign claim will have to make necessary accommodations to verify that the claim is not returned as unprocessable due to the lack of a zip code. For durable medical, orthotic and prosthetic claims, the name address or PIN of the location where the order was accepted must be entered (durable medical equipment Medicare administrative contractor [DME MAC] only). This field is required. When more than one supplier is used, a separate CMS-1500 claim form should be sued to bill each supplier. This item is completed whether the supplier’s personnel performs the work at the physician’s office or at another location. If modifiers QB or QU are billed, indicating the service was rendered in a Health Professional Shortage Area (HPSA), the physical location where the service was rendered shall be entered if other than home. If the supplier is a certified mammography screening center, enter the six-digit FDA approved certification number. 32a NPI 32b Non NPI Identifier Complete this item for all laboratory work performed outside a physician’s office. If an independent laboratory is billing, enter the place where the test was performed. Enter the NPI of the service facility as soon as it is available. The NPI may be reported on the CMS-1500 claim form (version 08-05) as early as January 1, 2007, and must be reported May 23, 2007, and later. Enter the ID qualifier 1C followed by one blank space and then the PIN of the service facility. Effective May 23, 2007, and later, 32b is not to be reported. Providers of service (namely physicians) shall identify the supplier's PIN when billing for purchased diagnostic tests. For durable medical, orthotic and prosthetic claims, enter the PIN (of the location where the order was accepted) if the name and address was not provided in Item 32 (DMERC/DME MAC only). 21 Jurisdiction B DME MAC Supplier Manual Chapter 11: Claim Submission [MARCH 2008] Item # 33 33a Description Physician’s, supplier’s billing name, address, zip code and phone NPI 33b Non NPI Cause Reject Yes Special Instructions Enter the provider of service/supplier's billing name, address, ZIP code, and telephone number. This is a required field. Effective May 23, 2007, and later, the provider/supplier must enter the NPI of the billing provider or group. The NPI may be reported on the CMS-1500 claim form (version 08-05) as early as January 1, 2007. This is a required field. Enter the ID qualifier 1C followed by one blank space and then the PIN of the billing provider or group. Effective May 23, 2007, and later, 33b is not to be reported. Suppliers billing the DMERC/DME MAC will use the National Supplier Clearinghouse (NSC) number in this item. MAILING ADDRESS All completed DMEPOS paper claims should be mailed to: DMEPOS Claims P.O. Box 7027 Indianapolis, Indiana 46207-7027 RESOURCES A CMS Web-based training course can be located at http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=1 The CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 26 The National Uniform Claim Committee: www.nucc.org 22 Jurisdiction B DME MAC Supplier Manual Chapter 12: Electronic Data Interchange [MARCH 2008] 12 Electronic Data Interchange ELECTRONIC MEDIA CLAIMS All Health Insurance Portability and Accountability Act (HIPAA) compliant electronic claims are subject to a 14-day payment floor. Claims submitted on paper are subject to a 29-day payment floor. By submitting claims electronically, both Medicare and health care suppliers can process transactions faster due to the difference in these payment floors. Other electronic data interchange (EDI) advantages include: increased cash flow; ease of billing electronically (support is available); lower administrative, postage and handling costs; added efficiency and accurate claims filing—data is received precisely as input by the supplier’s office, eliminating the chance of processing errors; receipt of the Front-End Edit Report—a confirmation that can be downloaded via modem within 48-hours of transmission (this report verifies the acceptance of claims and Certificates of Medical Necessity [CMNs] and/or Durable Medical Equipment [DME] Information Forms [DIFs]); claims transmitted for a beneficiary who resides in another Jurisdiction are automatically transferred to the appropriate DME MAC based on the beneficiary’s address listed on the claim* availability of: – Claim Status Inquiry (CSI) including beneficiary eligibility information – electronic remittance advice (ERA) – electronic funds transfer (EFT); and ability to submit claims and CMNs and DME MAC Information Forms (DIFs) seven days a week, including holidays. * Claims are transferred to another DME MAC jurisdiction based on the beneficiary address listed in the electronic claim. A transferred claim will not be processed by the DME MAC jurisdiction that receives the transferred claim, unless the supplier has a signed EDI enrollment form on file with that jurisdiction. Contact the appropriate jurisdiction(s) to receive an EDI enrollment form, when necessary. Jurisdiction A: Jurisdiction C: Jurisdiction D: NHIC Corp. Telephone: 866-563-0049 www.medicarenhic.com CIGNA Government Services Telephone: 888-613-9271 www.palmettogba.com/JCEDI Noridian Administrative Services Telephone: 866-224-3094 www.cignagovernmentservices.com 1 Jurisdiction B DME MAC Supplier Manual Chapter 12: Electronic Data Interchange [MARCH 2008] ADMINISTRATIVE SIMPLIFICATION COMPLIANCE ACT Section 3 of the Administrative Simplification Compliance Act (ASCA), Public Law (PL) 107-105, and the implementing regulation at 42 CFR 424.32 require that all initial claims for reimbursement under Medicare (except from small providers) be submitted electronically as of October 16, 2003, with limited exceptions. Initial claims are those claims submitted to a Medicare fee-for-service carrier, durable medical equipment Medicare administrative contractor (DME MAC), or fiscal intermediary for the first time, including: resubmitted previously rejected claims; claims with paper attachments; demand claims; claims where Medicare is secondary and there is only one primary payer; and nonpayment claims. Medicare is prohibited from payment of claims submitted in a non-electronic manner that do not meet the limited exceptions criteria. Claims required to be submitted electronically effective October 16, 2003, and later must comply with the appropriate claim standards adopted for national use under HIPAA (see the Electronic Format section of this chapter). The mandatory electronic claim submission requirement does not apply to claims submitted by beneficiaries, suppliers that only furnish services outside of the United States, claims submitted to Medicare managed care plans, or to health plans other than Medicare. Further details on the ASCA provision, exception criteria and how to apply for a waiver can be found on the National Government Services, Inc. Web site at www.adminastar.com/Providers/EDI/DMERC/ASCA/ASCA.html. Reference Chapter 24, Section 90 of the Centers for Medicare & Medicaid Services (CMS) InternetOnly Manual (IOM) Publication 100-04, Medicare Claims Processing Manual for further details on ASCA at www.cms.hhs.gov/manuals/downloads/clm104c24.pdf. ELECTRONIC FORMAT Medicare durable medical equipment (DME) claims are submitted via direct transmission. The acceptable Medicare HIPAA claims format is the ANSI X12N Version 4010A1 837 transaction and the National Council for Prescription Drug Programs (NCPDP). The Secretary of Health and Human Services has established, under part 162 of title 45 of the Code of Federal Regulations, the NCPDP Telecommunications Standard Version 5.1 and Batch Standard 1.1 as the standard for electronic retail pharmacy drug claims. This standard will be used by all health plans, including DME MACs that process retail pharmacy drug transactions. All other claims submitted to Medicare by pharmacies, other than retail pharmacy drug claims, must be submitted electronically in the ANSI X12N Version 4010A1 837 Health Care Claim format, and must be submitted in a separate transmission from the NCPDP retail drug claims. HIPAA version implementation guides may be downloaded at www.wpc-edi.com. 2 Jurisdiction B DME MAC Supplier Manual Chapter 12: Electronic Data Interchange [MARCH 2008] The NCPDP implementation guide is available at www.ncpdp.org. Suppliers should visit the Specification page on the National Government Services Web site (www.NGSMedicare.com) prior to programming their system with the HIPAA compliant claim transaction. The Specifications page contains: current trading partner agreements; companion documents; supplemental guides; and communications software. To access the Specifications page, go to www.adminastar.com/Providers/EDI/DMERC/Specifications/Specifications.html. HOW TO BECOME AN ELECTRONIC SUBMITTER Step 1 Acquire software for electronic submission. Several options are available: Use a software vendor’s product. For a list of software vendors that have passed testing with National Government Services, view the “Approved Entities” list at www.adminastar.com/Providers/EDI/files/DMERCPassedANSIVendorList.pdf. Write a software program, utilizing the ANSI X12N Version 4010A1 837 transaction and/or NCPDP format for retail pharmacy drug claims. For more details see “Electronic Format” section of this chapter. Employ a billing service or clearinghouse. For a list of billing services that have passed testing with National Government Services, view the “Approved Entities” list at www.adminastar.com/Providers/EDI/files/DMERCPassedANSIVendorList.pdf. Note: If this option is selected, Steps 2 (applying for a sender ID) and 3 (testing) are not required. Order the National Government Services software program, Express Plus. The application is available on the National Government Services Web site or by contacting the Jurisdiction B DME MAC EDI Help Desk. More details on this software are available under the “Express Plus” section of this chapter. Note: If this option is selected, Steps 2 (applying for a sender ID) and 3 (testing) are not required. National Government Services e-commerce consultants assist the supplier in analyzing claim submission needs. Depending on the needs of the supplier, software recommendations will be made. The e-commerce consultants will help the supplier complete all steps necessary to become an electronic submitter. A list of the e-commerce consultants and contact information is located at the end of this chapter. 3 Jurisdiction B DME MAC Supplier Manual Chapter 12: Electronic Data Interchange [MARCH 2008] Step 2 Obtain an electronic sender ID with National Government Services. Once a software package has been selected, the supplier must apply for an electronic sender ID. This number may be used for any of the four DME MACs. If the supplier chooses to use the same electronic sender ID to submit claims or download reports with multiple DME MACs, it is necessary to register the sender ID with each DME MAC. Agreement forms are available on the National Government Services Web site (www.NGSMedicare.com) or by contacting the EDI Help Desk. To obtain a copy of the EDI agreement for new EDI submitters, go to www.adminastar.com/Providers/EDI/DMERC/Agreements/Agreements.html. Step 3 Test with National Government Services. Testing is recommended, but not required for those suppliers that obtain software from approved vendors. Testing is required for suppliers who write their own program. TESTING PROCESS AND REQUIREMENTS Testing is recommended, but not required for those suppliers that obtain software from approved vendors. Testing is required for suppliers, billing services and clearinghouses who currently use vendor supported or proprietary software that have not passed testing with National Government Services or is not listed on the National Government Services Approved Entities list. For the listing of software vendors, billing services and clearinghouses that have passed testing with National Government Services, view the “Approved Entities” list at www.adminastar.com/Providers/EDI/files/DMERCPassedANSIVendorList.pdf. The following information describes the steps for testing with National Government Services once an electronic sender ID is received. 1) The vendor or supplier will be contacted by a Jurisdiction B DME MAC EDI Help Desk technician. The technician will request the following information: The date of the first test file(s) to be transmitted The type of DME claims to be tested (Example: Hospital beds, diabetic supplies, orthopedic supplies) The type of CMNs and/or DIFs to be tested 2) A “DME Open 837 Testing Checklist” will be forwarded via e-mail or fax to the tester. The checklist must be completed and returned. The checklist will request: the vendor company name; 4 Jurisdiction B DME MAC Supplier Manual Chapter 12: Electronic Data Interchange [MARCH 2008] the vendor testing contact name and telephone number; and the electronic sender ID assigned by National Government Services. 3) Testing requirements: Include twenty-five (25) claims that cover all of the following scenarios: – Medicare Secondary Payer – Claims with a narrative – Claims without a narrative – CMNs and DIFs (if applicable) – National Drug Codes (NDC) (if applicable) – Legal representative – NCPDP (if applicable) 4) Once a test file(s) is received, the Jurisdiction B DME MAC EDI Help Desk technician will review the files for errors. If errors are present in the test files, the technician will contact and work with the tester until an accepted test file is received. If no errors are found in the test files, the technician will contact the tester to indicate that they have met the testing guidelines listed on their checklist. The date the tester passed testing will be noted in National Government Services’ records. Note: The EDI Jurisdiction B DME MAC Help Desk may be contacted toll free at 877-273-4334, option 1 or via e-mail at [email protected]. EXPRESS PLUS Express Plus (National Government Services’ software program) offers quick, simple and accurate electronic submissions of HIPAA compliant claims, CMNs, and DIFs for DME MAC suppliers. Express Plus also allows suppliers to submit Medicare Secondary Payer (MSP) claims. Express Plus uses a database that offers user maintained tables of patient demographics, diagnosis codes, Healthcare Common Procedure Coding System (HCPCS) codes, rendering and referring physicians, and claims information. Express Plus increases productivity because claim entry is fast and accurate. Express Plus contains online edits that check each claim for accuracy. The following items and services are included with the Express Plus software: The Express Plus manual The ability to submit claims electronically and receive reports, and Jurisdiction B DME MAC EDI Help Desk assistance through a toll-free number The hardware requirements necessary to operate Express Plus are: Computer: 386DX or higher processor IBM compatible computer with Windows 95 or greater Note: Express Plus will not work on Windows 3.1 5 Jurisdiction B DME MAC Supplier Manual Chapter 12: Electronic Data Interchange [MARCH 2008] Hard Drive Space: 50 megabytes Total Memory (RAM): 32 megabytes Available Memory: 512K Modem: 9600–28800 baud rate modem Note: The communications software provided will not work with a “cable modem” or DSL line. Printer: Any make/model CD-ROM Drive: Express Plus is only provided on CD-ROM To order the software, contact the EDI help desk or download the Express Plus agreement forms from the National Government Services Web site at www.adminastar.com/Providers/EDI/DMERC/Agreements/Agreements.html. Note: Express Plus does not have the capability to bill claims using the NCPDP format for retail pharmacy drugs claims. FRONT-END EDIT REPORT An electronic submitter may dial in (via modem) and pick up a Front-End Edit Report. This report lists how many claims were electronically accepted or rejected. It provides an explanation of all front-end errors on any claim that may be electronically rejected. Claims that are rejected on the front end will not enter the DME MAC claims processing system. It is the submitter’s responsibility to correct the error(s) and retransmit any rejected claims. The Front-End Edit Report also includes a CMN Reject Report. This report is attached to the Front-End Edit Report and lists rejected Certificates of Medical Necessity (CMNs) and/or DME Information Forms (DIFs) on accepted claims. A complete list of all error codes, messages and report examples are available in the DME MAC ANSI X12N 4010A1 Front-End Edit Error Manual on the National Government Services Web site at www.adminastar.com/Providers/EDI/DMERC/Manuals/Manuals.html. National Government Services also offers a computer-based training (CBT) course on Electronic Front-End Edit Reports. The CBT, titled “Electronic Front-End Reports,” provides general guidelines on how to avoid electronic front-end rejections. This CBT includes report examples and the steps to take for each electronic report received. To access this CBT on the National Government Services Web site go to www.adminastar.com/Providers/DMERC/Workshops/Workshops.html. 6 Jurisdiction B DME MAC Supplier Manual Chapter 12: Electronic Data Interchange [MARCH 2008] CLAIM STATUS INQUIRY/BENEFICIARY ELIGIBILITY All suppliers submitting claims electronically are eligible for Claim Status Inquiry (CSI). This applies to participating and nonparticipating suppliers. With access to CSI, submitters can view the status of all claims as they appear in the DME MAC claims processing system. This includes paid, denied and pending claims. The information can be searched by viewing all claims for a specific National Supplier Clearinghouse (NSC) number, a beneficiary Health Insurance Claim Number (HICN), or date(s) of service. Online eligibility is available through CSI. Online eligibility will provide information on a Medicare beneficiary concerning prior year and current year deductible, MSP information, and health maintenance organization (HMO) activity. The CSI application is available on the National Government Services Web site at www.adminastar.com/Providers/EDI/DMERC/Agreements/Agreements.html. A CSI user manual is available on the National Government Services Web site at www.adminastar.com/Providers/EDI/DMERC/Manuals/Manuals.html. ELECTRONIC REMITTANCE ADVICE The electronic remittance advice (ERA) enables receipt of payment information in an electronic file. This payment file is sent either weekly or daily depending upon the supplier’s need. Suppliers should check with their software vendor to determine if their system has the capability to print and/or post an ERA received by National Government Services. If software capability is in place, an ERA file created by Medicare allows automatic posting to an accounts receivable system. Once ERA is in place, the payment posting process is more efficient and accurate. The Medicare Remit Easy Print (MREP) software is available for suppliers to view and print HIPAAcompliant ERAs from their own computer. If your current system does not have ERA capability, the MREP software is available at no cost. This software is easy to use and will save suppliers currently receiving standard paper remittances (SPR) time and money. Note: SPR will no longer be mailed 45 days after the supplier number(s) has been setup for ERA. Suppliers submitting through a billing service or clearinghouse or a sender ID that is currently receiving ERAs, will no longer receive their SPRs effective with the completion of the ERA setup date. Below are a few comments from suppliers currently receiving the benefits of ERAs: “We just started using the Electronic Remittance Advice (ERA) one day and have enjoyed all the benefits since. The conversion for us was simple and easy.” “I did not think the ERA would have been as easy as it is. I am sorry I waited so long to get started.” “ERA download went very smoothly with close communication with customer service. No interruption in claim processing.” 7 Jurisdiction B DME MAC Supplier Manual Chapter 12: Electronic Data Interchange [MARCH 2008] “The ERA is relatively simple once the programming is in place. Cuts down on staff manually having to post these transactions.” “The conversion to ERA was painless. The reduced labor costs alone made the transition beneficial. Within fourteen days of submitting a claim, we had the claim adjudicated and when applicable, on its way to secondary processing. In the case of denials, we were able to act on them within days of submission. This has enabled us to, according to DMERCs new reporting tool; submit approximately 99 percent of claims cleanly.” Suppliers should confirm with their software vendor that their system has ERA capability. Note: An EDI Enrollment form must be on file with National Government Services to receive an ERA. For the Benefits, Frequently Asked Questions, Setup Instructions, to sign up for the ERA, or to download MREP, go to www.adminastar.com/Providers/EDI/DMERC/ERA/ERA.html. ELECTRONIC FUNDS TRANSFER Electronically deposited funds are available in the supplier’s account the day after Medicare transmits an electronic funds transfer (EFT) to the bank. Paper checks must be mailed, manually processed in the supplier’s office, deposited, and cleared by the bank. This means the EFT will usually be available to the supplier one week sooner than paper funds. Note: CMS requires that all new and current suppliers submitting a CMS-588 application to the National Supplier Clearinghouse for an additional location receive EFT The EFT application is available on the National Government Service Web site at www.adminastar.com/Providers/EDI/DMERC/Agreements/Agreements.html. JURISDICTION B DME MAC EDI HELP DESK 877-273-4334, Option 1 The Jurisdiction B DME MAC EDI Help Desk is available 8:00 a.m.–4:00 p.m. Eastern Time (ET), Monday through Friday. Note: The Jurisdiction B DME MAC Help Desk will be open until 6:00 p.m. ET for password reset calls only. Jurisdiction B DME MAC Help Desk support is also available at [email protected]. Issues that can be addressed by the Jurisdiction B DME MAC EDI Help Desk include: Acquiring a sender ID or Express Plus software Access to CSI, ERA, or EFT Connection to the National Government Services host Retrieve or interpret Front-End Edit Reports 8 Jurisdiction B DME MAC Supplier Manual Chapter 12: Electronic Data Interchange [MARCH 2008] Recreate reports and ERAs Clarification of format questions, and Assistance with the National Government Services Express Plus program PASSWORD RESET REQUESTS Password resets for electronic submitters may be requested via telephone, online (Web site), or fax. Please be sure to use only one of these methods for your password reset needs. Telephone Password Reset Requests The password reset team can be reached toll free at 877-273-4334. Online Password Reset Requests To have your password reset online, complete the required information found on the National Government Services Web site at www.adminastar.com/providers/edi/secure/passwordreset_enroll.cfm. Fax Password Request Form To obtain a copy of the Password Fax Request Form, go the National Government Services Web site at www.adminastar.com/providers/edi/secure/passwordreset_enroll.cfm. Once a password reset request has been submitted, a ticket number will be assigned and returned via the e-mail address or fax number given when the password reset process was initiated. The supplier will be assigned a temporary password within two business days of receipt; it will be communicated back to the supplier in the same manner as the request was received. E-COMMERCE CONSULTANTS Suppliers should contact the e-commerce consultants to: discuss EDI advantages; and analyze claims submission needs. Lisa Hare Indiana, Kentucky, Ohio, and suppliers in Jurisdictions A and C 804-746-7082 [email protected] Pat Graham Illinois, Michigan, Minnesota, Wisconsin, and suppliers in Jurisdiction D 414-459-2613 [email protected] 9 Jurisdiction B DME MAC Supplier Manual Chapter 12: Electronic Data Interchange [MARCH 2008] NATIONAL GOVERNMENT SERVICES WEB SITE www.NGSMedicare.com (Then select AdminaStar Federal) More details on the information provided in this chapter can be found in the EDI section of our Web site. For additional EDI information, go to www.adminastar.com/Providers/EDI/DMERC/DMERC.html. EDI LIST SERVE An EDI List Serve is available through the National Government Services Web site. By subscribing to the EDI List Serve, providers/suppliers will stay informed of EDI news, changes, and updates. To subscribe, go to the National Government Services Web site at www.adminastar.com/Providers/EDI/DMERC/ListServeSignUp.html Once subscribed, providers/suppliers will receive e-mails containing the latest EDI information. E-COMMERCE CONNECTION The E-Commerce Connection online newsletter, created by the National Government Services E-Commerce team, is published on a quarterly basis to make EDI information readily available for EDI submitters, software vendors, billing services, and clearinghouses. Every E-Commerce Connection issue contains useful tips on how to resolve electronic billing issues, up to date information regarding HIPAA and EDI, National Government Services’ software products, an opportunity to meet an EDI associate, and much more! Because National Government Services values the opinions of its customers, a Feedback Survey is also included in each issue. This survey gives suppliers the opportunity to comment and make suggestions for future issues. Download a copy of the E-Commerce Connection—available in HTML and PDF formats at www.adminastar.com/Providers/EDI/DMERC/ECommerceConnection.html. 10 Jurisdiction B DME MAC Supplier Manual Chapter 13: Level II HCPCS Codes and HCPCS Modifiers [MARCH 2008] 13 Level II HCPCS Codes and HCPCS Modifiers Level II HCPCS CODES Level II of the Healthcare Common Procedure Coding System (HCPCS) is a standardized coding system that is used primarily to identify products, supplies and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) when used outside a physician’s office. Because Medicare and other insurers cover a variety of services, supplies and equipment that are not identified by CPT codes, the HCPCS Level II codes were established for submitting claims for these items. The development and use of HCPCS Level II codes began in the 1980s. HCPCS Level II codes are also referred to as alphanumeric codes because they consist of a single alphabetical letter followed by four numeric digits, while CPT codes are identified using five numeric digits. Suppliers must use HCPCS Level II codes to identify items/services rendered to its Medicare beneficiaries when submitting claims to the durable medical equipment Medicare administrative contractor (DME MAC) for payment. National Government Services is the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC). One role of the DME MAC is to create and maintain local coverage determinations (LCDs), also referred to as medical policies, for certain DMEPOS items/services. Each LCD contains information vital to the supplier community in determining whether the item/service meets medical necessity guidelines. In addition, the LCDs offer HCPCS coding information as well as coding guidelines in the LCD-related article. Suppliers should visit the National Government Services Web site to view the LCDs and specific HCPCS requirements outlined therein. Suppliers may also view a HCPCS code file (non-LCD specific) on the National Government Services Web site. To view the LCDs and related HCPCS and/or HCPCS code file, go to www.NGSMedicare.com. Structure of HCPCS File Prior to utilizing the HCPCS file, suppliers should become familiar with the Structure of HCPCS file, which provides an explanation of the HCPCS file table. This file is available at www.adminastar.com/Providers/DMERC/HCPCSCodes/HCPCSCodes.html. HCPCS Jurisdiction List The Jurisdiction List indicates whether a code should be billed to the DME MAC or the local Medicare carrier. This file is also available at www.adminastar.com/Providers/DMERC/HCPCSCodes/HCPCSCodes.html. Noncovered Items The following HCPCS codes will be denied as noncovered when they are submitted to the DME MAC. These items either do not meet the requirements for a benefit category processed by the DME MAC (technical denial) or are statutorily excluded for reasons other than lack of medical necessity. These 1 Jurisdiction B DME MAC Supplier Manual Chapter 13: Level II HCPCS Codes and HCPCS Modifiers [MARCH 2008] items may be covered under other provisions of the law (e.g., as part of institutional care in a hospital or nursing facility, as an item incident to a physician’s service, etc.). However, in these circumstances, the claim would not be submitted to the DME MAC and/or would be submitted using a different code. A4210 A4250 A4261 A4335 A4554 A4490 A4495 A4500 A4510 A4554 A4565 A4575 A4627 A4670 A6000 A9190 A9270 A9300 E0191 E0220 E0230 E0231 E0232 E0238 E0241 E0242 E0243 E0244 E0245 E0246 E0270 E0273 E0274 E0315 E0625 E0700 E0746 E1300 E1355 J1055 Needle-free injection device, each Urine test or reagent strips or tablets (100 tablets or strips) Cervical cap for contraceptive use Disposable sheets and bags Disposable underpads Surgical stockings above knee length, each Surgical stockings thigh length, each Surgical stockings below knee length, each Surgical stockings full length, each Disposable underpads, all sizes, (e.g., chux’s) Slings Topical hyperbaric oxygen chamber, disposable Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler Automatic blood pressure monitor Non-contact wound warming wound cover for use with the non-contact wound warming device and warming card Personal comfort item Noncovered item or service Exercise equipment Heel or elbow protector, each Hot water bottle Cap or collar Non-contact wound warming device Warming card for use with the non-contact wound warming device and non-contact wound warming wound cover Non-electric heat pad, moist Bath tub wall rail, each Bath tub rail, floor base Toilet rail, each Raised toilet seat Tub stool or bench Transfer tub rail attachment Hospital bed, institutional type includes: oscillating, circulating and stryker frame with mattress Bed board Over-bed table Bed accessories and boards or tables, any type Patient lift, kartop, bathroom or toilet Safety equipment (e.g., belt, harness or vest) Biofeedback therapy for the treatment of urinary incontinence Whirlpool, non-portable (overtub type) Stand rack Injection, medroxyprogesterone acetate for contraceptive use, 150 mg 2 Jurisdiction B DME MAC Supplier Manual Chapter 13: Level II HCPCS Codes and HCPCS Modifiers [MARCH 2008] J3520 J3535 J3570 J7300 J8499 L3215 L3216 L3217 L3219 L3221 L3222 Q0144 V2025 V2600 V2610 V2615 V2760 V5008 V5010 V5011 V5014 V5020 V5030 V5299 V5336 Edetate disodium, per 150 mg Drug administered through a metered dose inhaler Laetrile, amygdalin, vitamin b17 Intrauterine copper contraceptive Prescription drug, oral, non chemotherapeutic, NOS Orthopedic footwear, ladies shoes, oxford Orthopedic footwear, ladies shoes, depth inlay Orthopedic footwear, ladies shoes, hightop, depth inlay Orthopedic footwear, mens shoes, oxford Orthopedic footwear, mens shoes, depth inlay Orthopedic footwear, mens shoes, hightop, depth inlay Azithromycin dihydrate, oral, capsules/powder, 1 gram Deluxe frame Hand held low vision aids and other nonspectacle mounted aids Single lens spectacle mounted low vision aids Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system Scratch resistant coating, per lens Hearing screening Assessment for hearing aid Fitting/orientation/checking of hearing aid Repair/modification of a hearing aid Conformity evaluation Hearing aids Hearing devices Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid) HCPCS MODIFIERS In some instances, insurers instruct providers that a HCPCS code must be accompanied by a code modifier to provide additional information regarding the service or item identified by the HCPCS code. Modifiers are used when the information provided by a HCPCS code descriptor needs to be supplemented to identify specific circumstances that may apply to an item or service. Following is a list of HCPCS modifiers. HCPCS Modifier A1 A2 A3 A4 A5 A6 A7 A8 A9 Action Code Long Description Dressing Dressing Dressing Dressing Dressing Dressing Dressing Dressing Dressing for for for for for for for for for 01 one wound two wounds three wounds four wounds five wounds six wounds seven wounds eight wounds nine or more wounds C C C C C C C C C 3 Code Add Date 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 Action Effective Date 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 20020701 Term Date Jurisdiction B DME MAC Supplier Manual Chapter 13: Level II HCPCS Codes and HCPCS Modifiers [MARCH 2008] HCPCS Modifier Action Code AU AV AW AX BA BO BP BR BU CC CR EJ EM EY FB C GA GB GK GL GS C Long Description C 20030101 Action Effective Date 20030101 C 20030101 20030101 C 20030101 20030101 C 20030101 20030101 C 20030101 20030101 C 20030101 20030101 C 19920101 19970101 C 19920101 19970101 C 19920101 19970101 C 19900101 19970101 C D 20050821 19910101 20050821 20000101 D 19910101 19970101 C 20030101 20030101 I 20060101 20070101 C C 19950101 20020101 19970101 20020101 C 20020101 20020101 C 20020101 20020101 D 20060101 20070101 01 Item furnished in conjunction with a urological, ostomy, or tracheostomy supply Item furnished in conjunction with a prosthetic device, prosthetic or orthotic Item furnished in conjunction with a surgical dressing Item furnished in conjunction with dialysis services Item furnished in conjunction with parenteral enteral nutrition (PEN) services Orally administered nutrition, not by feeding tube The beneficiary has been informed of the purchase and rental options and has elected to purchase the item The beneficiary has been informed of the purchase and rental options and has elected to rent the item The beneficiary has been informed of the purchase and rental options and after 30 days has not informed the supplier of his/her decision Procedure code change (use CC when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) Catastrophe/disaster related Subsequent claims for a defined course of therapy, e.g., EPO, sodium hyaluronate, infliximab Emergency reserve supply (for ESRD benefit only) No physician or other licensed health care provider order for this item or service Item provided without cost to provider, supplier or practitioner or credit received for replaced device (examples, but not limited to covered under warranty, replaced due to defect, free samples) Waiver of liability statement on file Claim being resubmitted for payment because it is no longer covered under a global payment demonstration Actual item/service ordered by physician, item associated with GA or GZ modifier Medically unnecessary upgrade provided instead of standard item, no charge, no advance beneficiary notice (ABN) Dosage of EPO or Darbepoietin Alfa has been reduced and maintained in 4 Code Add Date Term Date Jurisdiction B DME MAC Supplier Manual Chapter 13: Level II HCPCS Codes and HCPCS Modifiers [MARCH 2008] HCPCS Modifier Action Code GY GZ JA JB K0 K1 K2 K3 K4 KA KB KC KD KF A A Long Description Code Add Date Action Effective Date S 20020101 20020101 M 20020101 20020101 C C C 20070101 20070101 19930101 20070101 20070101 20030101 C 19930101 19970101 C 19930101 19970101 C 19930101 19970101 C 19930101 19970101 C 19940101 19970101 C 20030101 20030101 C 20050101 20050101 C 20040101 20040101 C 20040401 20040401 01 response to hematocrit or hemoglobulin level Item or service statutorily excluded or does not meet the definition of any Medicare benefit Item or service expected to be denied as not reasonable and necessary Administered intravenously Administered subcutaneously Lower extremity prosthesis functional level 0—does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility Lower extremity prosthesis functional level 1—has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator. Lower extremity prosthesis functional level 2—has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulatory. Lower extremity prosthesis functional level 3—has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to transverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. Lower extremity prosthesis functional level 4—has the ability or potential for prosthetic ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress, or energy levels, typical of the prosthetic demands of the child, active adult. Add on option/accessory for wheelchair Beneficiary requested upgrade for ABN, more than four modifiers identified on claim Replacement of special power wheelchair interface Drug or biological infused through DME Item designated by FDA as Class III device 5 Term Date Jurisdiction B DME MAC Supplier Manual Chapter 13: Level II HCPCS Codes and HCPCS Modifiers [MARCH 2008] HCPCS Modifier Action Code KH KI KJ KL KM KN KO KP KQ KR KS KX LL LR LS LT M2 MS NR NU PL QA QE QF QG QH A Long Description C 19940101 Action Effective Date 19970101 C 19940101 19970101 C 19940101 19970101 C C 20070701 19960101 20070701 20010101 C 19960101 20010101 C C 19970401 19970401 19970401 19970401 C 19970401 19970401 C D 20020101 19981001 20020101 19981001 C C 20020701 19840101 20020701 19970101 C D C 19870101 19910101 19840101 19970101 19970101 19970101 C C 20070101 19890101 20070101 19970101 C 19840101 19970101 C C C C 19840101 19890101 19960101 19890101 19970101 19970101 19961001 19970101 C 19890101 19970101 C 19890101 19970101 C 19890101 19970101 D 20030101 20030101 01 DMEPOS item, initial claim, purchase or first month rental DMEPOS item, second or third month rental DMEPOS item, parenteral enteral nutrition (PEN) pump or capped rental, months four to fifteen DMEPOS item, delivered via mail Replacement of facial prosthesis including new impression/moulage Replacement of facial prosthesis using previous master model Single drug unit dose formulation First drug of a multiple drug unit dose formulation Second or subsequent drug of a multiple drug unit dose formulation Rental item, billing for partial month Glucose monitor supply for diabetic beneficiary not treated with insulin Specific required documentation on file Lease/rental (use the LL modifier when DME equipment rental is to be applied against the purchase price) Laboratory round trip FDA-monitored intraocular lens implant Left side (used to identify procedures performed on the left side of the body) Medicare secondary payer (MSP) Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty New when rented (use the NR modifier when DME which was new at the time of rental is subsequently purchased) New equipment Progressive addition lenses FDA investigational device exemption Prescribed amount of oxygen is less than 1 liter per minute (lpm) Prescribed amount of oxygen exceeds 4 liters per minute (lpm) and portable oxygen is prescribed Prescribed amount of oxygen is greater than 4 liters per minute(lpm) Oxygen conserving device is being used with an oxygen delivery system Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b) 6 Code Add Date Term Date Jurisdiction B DME MAC Supplier Manual Chapter 13: Level II HCPCS Codes and HCPCS Modifiers [MARCH 2008] HCPCS Modifier QR QV RP RR RT UE VP Action Code Long Description D 20060101 Action Effective Date 20060101 D 20000919 20000919 C 19840101 19970101 C 19840101 19970101 C 19840101 19970101 C C 19840101 19840101 19970101 19970101 01 Item or service provided in a Medicare specified study Item or service provided as routine care in a Medicare qualifying clinical trial Replacement and repair—RP may be used to indicate replacement of DME, orthotic and prosthetic devices which have been in use for sometime. The claim shows the code for the part, followed by the RP modifier and the charge for the part. Rental (use the RR modifier when DME is to be rented) Right side (used to identify procedures performed on the right side of the body) Used durable medical equipment Aphakic patient Code Add Date Term Date THE STATISTICAL ANALYSIS DURABLE MEDICAL EQUIPMENT REGIONAL CARRIER The Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) is a national entity that provides services under contract for the Centers for Medicare and Medicaid Services (CMS). Palmetto GBA has been contracted by the CMS to serve as the SADMERC. The SADMERC provides data analysis support to the four DME MACs and guidance to manufacturers and suppliers on the proper use of the HCPCS, the means by which DMEPOS services are identified for Medicare billing. Additionally, the SADMERC performs a variety of national pricing functions for DMEPOS services, assists CMS with the DMEPOS fee schedules and analyzes DMEPOS fees to identify unreasonable or excessive reimbursement amounts. Manufacturers and suppliers should contact the SADMERC HCPCS Unit to obtain proper billing codes for DMEPOS items. In addition to coding assistance, manufacturers and suppliers may also obtain fee schedule prices. A function of the SADMERC is to help determine the appropriate HCPCS code to use when submitting claims to Medicare. A HCPCS code identifies the DMEPOS being billed. Contact Information SADMERC P.O. Box 100143 Columbia, South Carolina 29202-3143 Mail Code: AG-370 Phone: 877-735-1326 7 Jurisdiction B DME MAC Supplier Manual Chapter 13: Level II HCPCS Codes and HCPCS Modifiers [MARCH 2008] Hours Available: 9:00 a.m.–4:00 p.m. Monday, Tuesday, Thursday and Friday, Eastern Time (ET) 9:00 a.m.–6:00 p.m. Wednesday, ET Additional information is available on the SADMERC Web site at www.palmettogba.com/sadmerc. Durable Medical Equipment Coding System The Durable Medical Equipment Coding System (DMECS) provides HCPCS coding assistance and national pricing information via searches for: HCPCS Level II codes and modifiers DMEPOS products, and CMS national fee schedules The DMECS is available through the SADMERC (Palmetto GBA) and provides coding assistance to the public that is reflective of DME MAC policies and guidelines. DMECS is designed to assist the public with the coding of DMEPOS products for submission to the DME MAC. DMECS currently has four interactive components that work together to provide HCPCS coding information. 1) 2) 3) 4) Search Search Search Search by HCPCS Information for Modifier for Fee Schedule DMEPOS Product Classification List DMECS is available on the SADMERC Web site at www.palmettogba.com/dmecs. 8 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] 14 DMEPOS Payment Categories The durable medical equipment (DME) fee schedules include items of DME as well as supplies needed to use the DME and are divided into the following categories: Inexpensive or other routinely purchased DME Items requiring frequent and substantial servicing Customized items Other prosthetic and orthotic devices Capped rental items Oxygen and oxygen equipment Surgical dressings Parenteral and enteral nutrition (PEN) (effective January 1, 2002) Therapeutic shoes and inserts (effective January 1, 2005) INEXPENSIVE OR OTHER ROUTINELY PURCHASED DME This is defined as equipment whose purchase price does not exceed $150, or equipment that is acquired at least 75 percent of the time by purchase. Equipment in this category may be purchased or rented. Purchases are reimbursed in a lump sum, minus any previous rental payments. All claims for purchase must specify whether the equipment is new (NU) or used (UE), using the appropriate modifier. If the supplier fails to indicate whether the equipment is new or used on an assigned claim, the durable medical equipment Medicare administrative contractor (DME MAC) will assume the equipment is used. If a nonassigned claim does not specify whether the equipment is new or used, the DME MAC will generate a development letter to the supplier for this information. If the equipment is rented, monthly rental payments will be made as long as the item is supplied, or until the purchase price is reached. ITEMS REQUIRING FREQUENT AND SUBSTANTIAL SERVICING Equipment in this category is paid on a rental basis only. Payment is based on the monthly fee schedule amounts until the medical necessity ends. No payment is made for the purchase of equipment, maintenance and servicing, or for replacement of items in this category. Supplies and accessories are not allowed separately. CUSTOMIZED ITEMS Coverage and allowable amounts for custom equipment will be decided by an individual evaluation based on medical indication. 1 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] The beneficiary’s physician must prescribe the customized equipment and provide information regarding the patient’s physical and medical status to warrant the need for the equipment. Payment with respect to a covered item that is uniquely constructed or substantially modified to meet the specific needs of an individual patient should be made in a lump-sum amount. The payment amount for the purchase of a customized item is based upon the DME MACs individual consideration for that item. Suppliers must submit the following documentation for these items for coverage to be considered: Detailed description of the item Description of feature(s) that make this item unique Acquisition or production cost of the item (i.e., line item cost of materials and/or labor) Manufacturer name, product name and product number The date of service for custom-made equipment is the actual date the beneficiary receives the item. Do not use the date the item was ordered when billing Medicare. OTHER PROSTHETIC AND ORTHOTIC DEVICES These items consist of all prosthetic and orthotic devices excluding: Items requiring frequent and substantial servicing Certain customized items Transcutaneous electrical nerve stimulators (TENS) Parenteral/enteral nutritional supplies and equipment, and Intraocular lenses Other than these exceptions, prosthetic and orthotic devices will be paid on a lump-sum purchase basis. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATORS For TENS, modifier RR must be entered on the claim when rented for a patient with acute postoperative pain or as a trial for patients with chronic pain. For claims submitted with dates of service on or after January 1, 2007, a Certificate of Medical Necessity (CMN) for a TENS rental will not be required. A CMN is only required for a TENS purchase for claims with dates of service on or after January 1, 2007. If, after the trial period, the physician determines it would be of benefit for the patient to purchase the TENS unit, a claim for purchase may be submitted. Payment for purchase is made in a lump sum. Rental payments are not deducted from the purchase allowance. 2 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] PARENTERAL AND ENTERAL NUTRITION PUMPS Parenteral and enteral nutrition (PEN) pumps are covered under the provisions of the prosthetic benefit. However, payment policies for these pumps generally follow the rules for capped rental items. The beneficiary has the option of either purchasing or renting the pump from the supplier. The DME MAC will make no more than 15 rental payments. The beneficiary has the option of purchasing a PEN pump with the initial claim or at any time during the rental period. However, PEN pump suppliers must notify the beneficiary of the option to purchase the pump with the initial claim. The supplier must use modifiers BR, BU, and BP when submitting claims for rental months 10–12. If the beneficiary decides to purchase the pump after rental payments have been paid, the purchase allowance will be equal to the used purchase allowance, minus the amount previously allowed for the rentals. The 25 percent rental allowance reduction for months 4–15 does not apply to PEN pumps. If the beneficiary chooses to rent the pump to the 15-month rental limit, the supplier is entitled to periodic maintenance and servicing payments. Necessary maintenance and servicing of pumps may include repairs and extensive maintenance that involves the breaking down of sealed components, or performing tests that require specialized testing equipment not available to the beneficiary or nursing home. The DME MAC will pay only for actual incidents of maintenance, servicing or replacements. For enteral pumps, the DME MAC pays no more than ½ rental payment every six months, beginning six months after the last rental period. For parenteral pumps, the DME MAC pays no more than 1/2 rental payment every three months, beginning three months after the last rental period for the pump. The supplier should keep written proof of maintenance and servicing of the pump on file. Claims for replacement of parenteral/enteral pumps purchased more than eight years ago will be considered for payment. Modifier MS (Maintenance and servicing) is used in this category. Note: For additional details regarding payment for PEN, please reference the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 30.7.1 (Payment for Parenteral and Enteral Pumps). HOME DIALYSIS SUPPLIES Before Medicare can approve home dialysis supplies for a beneficiary, a CMS-382 ESRD Beneficiary Selection Form must be filed. The CMS-382 ESRD Beneficiary Selection Form is located at the end of this chapter. If the beneficiary chooses to receive home dialysis supplies and equipment from a renal dialysis facility (i.e., Method I), the claims submitted for payment will be processed by the Medicare Part A fiscal intermediary. The DME MAC processes claims for beneficiaries who have chosen to receive their supplies and equipment from an independent supplier (i.e., Method II). Suppliers should obtain the original CMS-382 ESRD Beneficiary Selection Form and submit a copy to the Medicare fiscal intermediary to update the selection records. Note: The DME MAC does not record or update Method Selection changes. 3 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] CAPPED RENTAL ITEMS Items in this category are paid on a monthly rental basis not to exceed a period of continuous use of 13 months. Rental Fee Schedule For the first three rental months, Medicare pays 80 percent of the Medicare allowed amount from the Medicare fee schedule. For each of the remaining months of rental, the fee schedule amount allowance will be reduced by 25 percent. For example: If the normal fee schedule allowance for an item is $100, Medicare would allow $100 for the first three months of rental and then $75 for each month after. After paying the rental fee schedule amount for 13 months, no further payment may be made except for payments for maintenance and servicing. Payments During a Period of Continuous Use Payment for items in this category may not exceed a period of continuous use longer than 13 months. After 13 months of rental have been paid, the beneficiary owns the DME item, and after that time Medicare pays for reasonable and necessary maintenance and servicing (i.e., parts and labor not covered by a supplier’s or manufacturer’s warranty) of the item. This provision applies to beneficiaries renting an item for which the first rental month occurs on or after January 1, 2006. Suppliers should continue to use modifiers KH, KI, and KJ in the manner as previously instructed for capped rental DME. For claims with an initial date of service on or after January 1, 2006, suppliers are no longer required to give beneficiaries a purchase option in the tenth month of rental. Healthcare Common Procedure Coding System (HCPCS) modifiers BP, BR, and BU should not be submitted. However, for rental periods that began prior to January 1, 2006 suppliers should use modifiers BP, BR, and BU. Capped rental items furnished to beneficiaries prior to January 1, 2006, will continue to be paid under the payment rules in effect prior to the Deficit Reduction Act (DRA) of 2005 changes. Note: This chart excludes Power Wheelchairs Capped Rental (Excluding Power Wheelchairs) Flow Chart Day 1 = beneficiary rents DME Î 10th month = supplier gives beneficiary the option to rent or buy No response from beneficiary Î Payments made through 15th month Beneficiary declines purchase option Î Payments made through 15th month Î Rental paid through 13th month—then supplier transfers title to beneficiary Ò Î 11th month Î Ô Beneficiary accepts purchase option 4 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] A period of continuous use allows for temporary interruptions in the use of equipment. Interruptions must exceed 60 consecutive days plus the days remaining in the rental month in which the use ceases (not calendar month, but the 30-day rental period) in order for a new 13-month rental period to begin. When an interruption continues beyond the end of the rental month in which use ceases, no additional payment will be made until the use of the item resumes. A new date of service will be established when use resumes. Unreimbursed months of interruption will not apply toward the 13-month limit. If the interruption is greater than 60 consecutive days (plus the days remaining in the rental month in which need ceases), the supplier must inform the DME MAC if interruption occurs and provide documentation for the reason it occurred. If notification is not received by the DME MAC, payments will continue as though no interruption occurred. If the interruption reasons are justified, a new 13-month rental period may be started. Capped Rental Situations If equipment is changed to different but similar equipment, and the beneficiary’s condition has substantially changed to support the medical necessity for the new item, a new 13-month period will begin. Otherwise, the rental will continue to count against the current 13-month period and payment will be based on the least expensive medically appropriate equipment. If the 13-month period has already expired, no additional rental payment will be made for modified or substituted equipment in the absence of substantial change in medical need. If modification is added to existing equipment and there is a substantial change in medical need, the 13-month rental period for the original equipment continues and a new 13-month rental period begins for the added equipment. Change of Address If the beneficiary moves during or after the 13-month period, either permanently or temporarily, it does not result in a new rental episode. Change in Suppliers If the beneficiary changes suppliers during the 13-month rental period, a new rental period will not begin. Replacement of Capped Rental Equipment If a capped rental item of equipment has been in continuous use by the patient and if the item is lost or irreparably damaged prior to the reasonable useful lifetime, which is five years, the patient may elect to obtain a new piece of equipment. Payment for replacement capped rental equipment will be made in accordance with the capped rental guidelines of this chapter or if the item is an electric wheelchair, the item will be paid based in accordance with the electric wheelchair guidelines found in this chapter. Purchase Options for Power Wheelchairs Suppliers must give beneficiaries entitled to electric wheelchairs the option of purchasing at the time the supplier first furnishes the item. If the beneficiary chooses to purchase, payment will be made on 5 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] a lump sum purchase basis. If the beneficiary declines the purchase in the first month, payment will be made on a rental basis through the 13th month. On the first day after 13 continuous rental months have been paid, the supplier must transfer title of equipment to the beneficiary. OXYGEN AND OXYGEN EQUIPMENT Since 1989, suppliers have been paid a monthly payment amount for furnishing stationary oxygen equipment and oxygen contents to Medicare beneficiaries. In addition, suppliers have been paid an add-on fee for furnishing portable oxygen equipment to patients when medically necessary. These payments were made for the duration of use of the equipment, provided that Medicare Part B coverage and eligibility criteria were met. However, Section 5101(b) of the Deficit Reduction Act (DRA) of 2005 established a 36-month (three year) limit, or cap, on monthly payments for stationary and portable oxygen equipment. This cap applies to oxygen equipment furnished on or after January 1, 2006, and applies to all claims for the following HCPCS codes: E0424 E0431 E0434 E0439 E1390 E1391 E1392 E1405 E1406 Stationary gaseous oxygen system Portable gaseous oxygen system Portable liquid oxygen system Stationary liquid oxygen system Oxygen concentrator, single delivery port Oxygen concentrator, dual delivery port Portable oxygen concentrator Oxygen and water vapor enriching system with heated delivery Oxygen and water vapor enriching system without heated delivery Continuous use of DME as it applies to capped rental items is defined in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 30.5.4 and also applies to oxygen equipment for the purpose of implementing the DRA Section 5105(b). Payments for an item described above will terminate after a period of continuous use of 36 months. The DME MAC will count as a month, the date the oxygen equipment was initially furnished to the day before the same date in the following month and each rental month thereafter until the 36th month anniversary is reached. On the first day after the 36th month anniversary for which payment has been made, the supplier must transfer title for the stationary and/or portable oxygen equipment to the beneficiary. On that same day that title for the equipment is transferred to the patient, monthly payments can begin to be made for oxygen contents used with patient owned gaseous and liquid oxygen equipment. The HCPCS codes for oxygen contents are: E0441 E0442 E0443 E0444 Stationary gaseous contents used with patient owned gaseous stationary system Stationary liquid contents used with patient owned liquid stationary system Portable gaseous contents used with patient owned gaseous portable system Portable liquid contents used with patient owned liquid portable system 6 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] The DME MAC will begin the 36-month count on January 1, 2006 for beneficiaries that were receiving oxygen therapy prior to January 1, 2006. Months prior to January 2006 will not be included in the 36-month count. The DME MAC will make payment for maintenance and servicing (i.e., parts and labor not covered by a supplier’s or manufacturer’s warranty) of patient owned stationary or portable oxygen equipment following the same rules and methods that apply to patient-owned equipment in the inexpensive or routinely purchased DME and capped rental DME payment categories. These rules are located in the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 14, Section 110.2. The billing instructions located in CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 130.7 also apply to claims for maintenance and servicing of oxygen equipment. All other existing rules regarding oxygen (e.g., break in service rules) continue to apply. Fee schedule payments for stationary oxygen system rentals are all-inclusive and represent a monthly allowance per beneficiary. This allowance includes payment for the equipment, contents, and accessories furnished during a rental month. Modifiers The monthly payment amount for stationary oxygen is subject to adjustment depending on the amount of oxygen prescribed (liters per minute, or LPM) and whether or not portable oxygen has been prescribed. QE—Use if the prescribed amount of oxygen is less than 1 LPM QF—Use if the prescribed amount of oxygen exceeds 4 LPM and portable oxygen is prescribed QG—Use if the prescribed amount of oxygen is greater than 4 LPM QH—Use if an oxygen conserving device is being used with an oxygen delivery system Oxygen Contents/Units When a stationary oxygen system is being rented, the monthly allowance includes payment for all required contents. It would be considered “unbundling” if the supplier billed the beneficiary separately for contents in this scenario. If the beneficiary owns an oxygen stationary system other than an oxygen concentrator or uses a portable system only, payment may be made for contents. This is also a monthly allowance so contents should only be billed once a month, not daily or weekly. Although suppliers should document the proper units of service to indicate the amount of contents provided, the content allowables are monthly fees and will not vary according to the number of units provided. If the patient owns a stationary system and uses a portable system, the portable content fee is never payable in addition to the regular content fee. Oxygen Equipment and Contents Billing Chart The following tables indicate what oxygen fee schedule component is billable/payable under various transaction scenarios. 7 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] Situation: Beneficiary Uses a Stationary System Only 1) Rental Type of System Concentrator Gaseous Liquid Stationary Contents Code No* No* No* Portable Add-on Code Portable Contents Code No No No No No No Stationary Contents Code No* E0441 E0442 Portable Add-on Code Portable Contents Code No No No No No No 2) Purchase Type of System Concentrator Gaseous Liquid Situation: Beneficiary Uses Both a Stationary and Portable System 1) Rents Stationary/Rents Portable Type of System Concentrator Gaseous Liquid Stationary Contents Code No* E0441 E0442 Portable Add-on Code Portable Contents Code E0431, E0434 E0431, E0434 E0431, E0434 No* No* No* Portable Add-on Code Portable Contents Code No No No No* No* No* Portable Add-on Code Portable Contents Code No No No E0443, E0444 No* No* Portable Add-on Code Portable Contents Code E0431, E0434 E0431 E0434 E0443, E0444 No** No** 2) Rents Stationary/Owns Portable Type of System Concentrator Gaseous Liquid Stationary Contents Code No* No* No* 3) Owns Stationary/Owns Portable Type of System Concentrator Gaseous Liquid Stationary Contents Code No* E0441 E0442 4) Owns Stationary/Rents Portable Type of System Concentrator Gaseous Liquid Stationary Contents Code No* E0441 E0442 Situation: Beneficiary Uses a Portable System Only 1) Rents Portable System Type of System Gaseous Liquid Stationary Contents Code No No 8 Portable Add-on Code Portable Contents Code E0431 E0434 E0443 E0444 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] 2) Owns Portable System Type of System Gaseous Liquid Stationary Contents Code No No Portable Add-on Code Portable Contents Code No No E0443 E0444 * Contents are included in stationary system reimbursement. ** The portable contents reimbursement is included in the reimbursement for the stationary contents. Guidelines for Oxygen and Oxygen Equipment prior to January 1, 2006 Oxygen equipment is reimbursed on a rental basis only, for as long as the equipment is medically necessary. The equipment rental allowance includes reimbursement for the oxygen contents. If the contents are billed separately for a rented system, they will be denied as not separately payable. Claims for the purchase of oxygen equipment will be denied as noncovered services. Oxygen contents will only be reimbursed separately when the beneficiary owns an oxygen system, or rents or owns only a portable oxygen system. For gaseous or liquid systems or contents, one unit of service = one rental month. Do not report units of service in cubic feet or pounds. Concentrators E1390 Oxygen concentrator, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate If the beneficiary also rents a portable system, there should be a charge for a portable “add-on.” There should not be an additional charge for the portable contents—reimbursement for the portable contents will be included in the reimbursement for the stationary system. Example: Beneficiary rents a concentrator and a gaseous portable system. E1390RR E0431RR Concentrator Gaseous portable system Gaseous and Liquid Stationary Systems E0424 E0439 Stationary compressed gaseous oxygen system, rental; includes contents (per unit), regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing Stationary liquid oxygen system, rental; includes use of reservoir, contents (per unit), regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing If the beneficiary also rents a portable system, there should be a charge for a portable “add-on.” There should not be an additional charge for the portable contents. The portable contents reimbursement will be included in the reimbursement for the stationary system. 9 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] Example: Beneficiary rents a liquid stationary system and a portable liquid system. E0439RR E0434RR Stationary system Portable system Portable Oxygen Systems E0431 E0434 Portable gaseous oxygen system, rental; includes regulator, flowmeter, humidifier, cannula or mask, and tubing Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adapter, contents gauge, cannula or mask, and tubing These codes are to be used as an “add-on” when a portable system is rented with a concentrator, a stationary gaseous, or a stationary liquid system. Stationary Equipment Content Codes E0441 E0442 Oxygen contents, gaseous, per unit, (for use with owned stationary gaseous systems or when both a stationary and portable gaseous system are owned) Oxygen contents, liquid, per unit, (for use with owned stationary liquid systems or when both a stationary and portable liquid system are owned) Oxygen contents for stationary equipment may only be reimbursed separately when the beneficiary owns a stationary system or owns both stationary and portable systems. Claims should be billed on a monthly basis (as with the equipment rental claims). Portable Oxygen Contents E0443 E0444 Portable oxygen contents, gaseous, per unit (for use only with portable gaseous systems when no stationary gas or liquid system is used) Portable oxygen contents, liquid, per unit (for use only with portable liquid systems when no stationary gas or liquid system is used) A portable contents fee can only be paid separately in the following situations: When the beneficiary owns a concentrator and rents or owns a portable system When the beneficiary rents or owns a portable system and no stationary equipment exists Claims should be billed on a monthly basis. When a claim for HCPCS code E0443 or E0444 is denied because payment is being made for a stationary oxygen system, the denial will not be treated as a coverage denial. It is a charge reduction, since the reason for the denial is that base price allowed charges for portable contents were included in the calculation of the stationary contents and equipment fee. On assigned claims, any attempt by the supplier to collect charges from the beneficiary for denied portable oxygen contents claims will be considered an assignment violation. 10 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] Oxygen Modifiers The monthly fee schedule reimbursement amount can be increased or decreased depending upon the amount of oxygen prescribed (LPM) and whether or not portable oxygen has been used. To make the proper payment adjustments, claims must indicate the appropriate HCPCS modifier as described (where applicable). If the prescribed amount of oxygen is from 1–4 LPM, no modifier is used. QE QF QG QH If the prescribed amount of oxygen is less than 1 LPM, the monthly payment amount will be reduced 50 percent by the system when this modifier is used. These claims will be reviewed by the medical staff to ensure the home oxygen therapy coverage requirements are met. Prescribed amount of oxygen exceeds 4 liters per minute (LPM) and portable oxygen is also prescribed. If the prescribed amount of oxygen is greater than 4 LPM, the monthly payment amount will be increased 50 percent by the system when this modifier is used. These claims will be reviewed by the medical staff to ensure the home oxygen therapy coverage requirements are met. Use this modifier when the beneficiary is using an oxygen conservation device with the oxygen system. There is no payment adjustment for use of this device. Modifiers QE, QF, and QG may be used only with a stationary gaseous system (E0424), a stationary liquid system (E0439), or a concentrator (E1390). They should not be used with the portable system HCPCS codes (E0431 or E0434), or with the oxygen contents HCPCS codes (E0441–E0444). Modifier QH may be used with any oxygen code. Modifier RR would be used on equipment rental codes in addition to the Q modifiers (e.g., E0424RRQG). Oxygen Accessories Accessories, including but not limited to cannulas (A4615), humidifiers (E0555), masks (A4620, A4621), mouthpieces (A4617), nebulizer for humidification (E0580), oxygen conserving devices (A9900), regulators (E1353), transtracheal catheters (A9900) and tubing (A4616), are included in the allowance for rented systems. The supplier must provide any accessory ordered by the physician. Accessories are separately payable only when they are used with a patient-owned system that was purchased prior to June 1, 1989. Accessories used with a patient-owned system that was purchased on or after June 1, 1989 will be denied as noncovered. Procedure Codes A4615 A4616 A4617 A4619 A4620 A4621 11 E0455 E0555 E0580 E1353 E1355 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] Oxygen Equipment Help Chart A) Situation: Beneficiary uses a stationary system only 1) Rental Type of System Concentrator Gaseous Liquid Stationary Contents Code No* No* No* Portable Add-on Code Portable Contents Code No No No No No No Portable Add-on Code Portable Contents Code No No No No No No * Contents are included in stationary system reimbursement. 2) Purchase Type of System Concentrator Gaseous Liquid Stationary Contents Code No E0441 E0442 B) Situation: Beneficiary uses both a stationary and portable system 1) Rents Stationary/Rents Portable Type of System Concentrator Gaseous Liquid Stationary Contents Code No* No* No* Portable Add-on Code Portable Contents Code E0431, E0434 E0431 E0431, E0434 No* No* No* Portable Add-on Code Portable Contents Code No No No No* No* No* Portable Add-on Code Portable Contents Code No No No E0443, E0444 No* No* Portable Add-on Code Portable Contents Code E0431, E0434 E0431 E0434 E0443, E0444 No* No* * Contents are included in stationary system reimbursement. 2) Rents Stationary/Owns Portable Type of System Concentrator Gaseous Liquid Stationary Contents Code No* No* No* * Contents are included in stationary system reimbursement. 3) Owns Stationary/Owns Portable Type of System Concentrator Gaseous Liquid Stationary Contents Code No* E0441 E0442 * Contents are included in stationary system reimbursement. 4) Owns Stationary/Rents Portable Type of System Concentrator Gaseous Liquid Stationary Contents Code No E0441 E0442 * The portable contents reimbursement is included in the reimbursement for the stationary contents. 12 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] C) Situation: Beneficiary uses a portable system only 1) Rents Portable System Type of System Gaseous Liquid Stationary Contents Code No No Portable Add-on Code Portable Contents Code E0431 E0434 E0443 E0444 Portable Add-on Code Portable Contents Code No No E0443 E0444 2) Owns Portable System Type of System Gaseous Liquid Stationary Contents Code No No REPAIRS, MAINTENANCE AND REPLACEMENT Under the circumstances specified below, payment may be made for repair, maintenance, and replacement of medically required DME, including equipment which had been in use before the user enrolled in Part B of the program. In addition, payments for repair and maintenance may not include payment for parts and labor covered under a manufacturer's or supplier’s warranty. A) Repairs To repair means to fix or mend and to put the equipment back in good condition after damage or wear. Repairs to equipment which a beneficiary owns are covered when necessary to make the equipment serviceable. If the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, no payment can be made for the amount of the excess. Repairs of rented equipment are not covered. This includes items in the frequent and substantial servicing, oxygen equipment, capped rental and inexpensive or routinely purchased payment categories which are being rented. A new CMN and/or physician’s order is not needed for repairs. B) Maintenance Routine periodic servicing, such as testing, cleaning, regulating, and checking of the beneficiary’s equipment, is not covered. The beneficiary is expected to perform such routine maintenance rather than the supplier or some other person who charges the beneficiary. Normally, purchasers of DME are given operating manuals which describe the type of servicing an owner may perform to properly maintain the equipment. It is reasonable to expect that beneficiaries will perform this maintenance. Thus, hiring a third party to do such work is for the convenience of the beneficiary and is not covered. However, more extensive maintenance which, based on the manufacturers’ recommendations, is to be performed by authorized technicians, is covered as repairs for medically necessary equipment which a beneficiary owns. This might include, for example, breaking down sealed components and performing tests which require specialized testing equipment not available to the beneficiary. Maintenance of purchased items that require frequent and substantial servicing or oxygen equipment is not covered. 13 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] When billing for maintenance and servicing claims suppliers must add the MS modifier to the HCPCS code. The following is a description of modifier MS: Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty C) Replacement Replacement refers to the provision of an identical or nearly identical item. Equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood, etc.). Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment. If the equipment has been in continuous use by the patient on either a rental or purchase basis for the equipment's useful lifetime, the beneficiary may elect to obtain a new piece of equipment. The reasonable useful lifetime of durable medical equipment is determined through program instructions. In the absence of program instructions, carriers may determine the reasonable useful lifetime of equipment, but in no case can it be less than five years. Computation of the useful lifetime is based on when the equipment is delivered to the beneficiary, not the age of the equipment. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary. Replacement may be reimbursed when a new physician order and/or new CMN, when required, is needed to reaffirm the medical necessity of the item. Cases suggesting malicious damage, culpable neglect, or wrongful disposition of equipment should be investigated and denied where the DME MAC determines that it is unreasonable to make program payment under the circumstances. The DME MACs refer such cases to the zone program integrity contractor (ZPIC). When filing a Medicare claim for replacement equipment prior to the reasonable useful lifetime of five years, modifier RP must be submitted on the claim. When billing with the RP modifier, documentation must be maintained in the beneficiary’s file and be available upon request from the DME MAC or the ZPIC. The following documentation must be included, but is not limited to: Reason for replacement New CMN when required Medical records Police reports Written explanations from the beneficiary These guidelines do not apply to breast prosthesis or limb prosthesis. Please refer to each individual local coverage determination and policy article on the National Government Services Web site at www.adminastar.com/Providers/DMERC/MedicalPolicy/MedicalPolicy.cfm for the exception to the reasonable useful requirements of five years for these items. 14 Jurisdiction B DME MAC Supplier Manual Chapter 14: DMEPOS Payment Categories [MARCH 2008] SAMPLE RENT/PURCHASE OPTION FOR POWER WHEELCHAIRS LETTER If you meet the Medicare coverage criteria for a power wheelchair prescribed by your physician, Medicare may help pay for it. Upon delivery of the power wheelchair, Medicare requires (specify name of supplier) to give you the option of either renting or purchasing the electric wheelchair. If you choose to purchase the power wheelchair, upon approval, Medicare pays 80 percent of the allowed purchase price in a lump sum amount. You are responsible for the 20 percent coinsurance amounts and, for nonassigned claims, the balance between the Medicare allowed amount and the supplier’s charge. However, you must elect to purchase the electric wheelchair at the time your medical equipment supplier furnishes you the item. If you choose to rent the power wheelchair and the Medicare coverage criteria are met, Medicare may pay a monthly rental fee for a period not to exceed 13 months, after which ownership of the electric wheelchair is transferred to you. During the rental period, you will be responsible for the 20 percent coinsurance payment for each month of the rental period, and for nonassigned claims: you will be responsible for the balance between the Medicare allowed amount and the supplier’s charge. Medicare requires (specify name of supplier) to convert your rental agreement to a purchase agreement after 13 months of rental. This means once Medicare has made the final 13th rental payment, title to the equipment is transferred to you and you will own the equipment. Once the power wheelchair is purchased, you are responsible for 20 percent of the service charge each time your equipment is actually serviced or repaired and, for nonassigned claims, the balance between the Medicare allowed amount and the supplier’s charge. Option: ______ Continued Rental ______ Purchase Beneficiary Signature: ______________________________________________________________ Date: ______________________________________________________________________________ 15 DEPARTMENT OF HEALTH & HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0372 ESRD BENEFICIARY SELECTION (Home Patients Only) PLEASE READ INSTRUCTIONS ON REVERSE BEFORE COMPLETING THIS FORM 1. NAME (Last, First, Middle Initial) 2. HEALTH INSURANCE CLAIM NUMBER (Medicare Claim Number) 3. DATE OF BIRTH (month/day/year) 4. SEX o Male o Female 5. PROVIDER NUMBER OF FACILITY PROVIDING HOME DIALYSIS TRAINING 5A. NAME AND ADDRESS OF FACILITY PROVIDING HOME DIALYSIS TRAINING 6. PROVIDER NUMBER OF FACILITY PROVIDING HOME DIALYSIS SUPPORT SERVICES 6A. NAME AND ADDRESS OF DIALYSIS FACILITY PROVIDING SUPPORT SERVICES o o o o 7. BENEFICIARY SELECTION, CHANGE OR CANCELLATION Initial Selection Cancellation Routine Method Selection Change o o o 8. TYPE OF DIALYSIS (Check One) Hemodialysis CAPD CCPD Method Exception (Refer to PRM, Part I-Chap. 27, §2740.2.D.) Intermediary approval required. Reason for Exception __________________________________________________________________________ ____________________________________________________________________________________________ 9. DATE HOME DIALYSIS TRAINING IS COMPLETED o 10. CHECK METHOD I OR II METHOD I – The ESRD facility indicated in #6 will supply all the equipment, supplies, and support services necessary for me to dialyze at home. o METHOD II – I will deal directly with one supplier for my home dialysis supplies and equipment, and my support services will be provided by the dialysis facility indicated above. 11. NAME AND ADDRESS OF THE DURABLE MEDICAL EQUIPMENT SUPPLIER THAT WILL PROVIDE THE SUPPLIES AND EQUIPMENT (Only appropriate if beneficiary chooses Method II) 12. If I have chosen Method II, by signing this form, I certify that I have only one Method II supplier. Further, I understand that if my supplier does not take assignment, Medicare will not pay anything toward my supplier’s bill. o Private Residence o Skilled Nursing Facility 13. CHECK LOCATION WHERE HOME DIALYSIS IS PROVIDED 14. BENEFICIARY SIGNATURE o Nursing Home 15. DATE BENEFICIARY SIGNS FORM (month/day/year) 16. DATE METHOD EXCEPTION TO BE EFFECTIVE (month/day/year) (INITIAL SELECTION CHANGES, ROUTINE SELECTION CHANGES, AND CANCELLATIONS BECOME EFFECTIVE ON JANUARY 1 OF THE YEAR FOLLOWING THE YEAR IN WHICH THIS FORM IS SIGNED) 17. The dialysis facility providing the home dialysis training is responsible for supplying this form to Medicare beneficiaries who select home dialysis and for sending the white copy of the completed form to the local Part A Intermediary (both Method I and Method II selections). Blank forms are available from the Intermediary. The white copy of this form must be sent to: THE LOCAL INTERMEDIARY ATTN: MEDICARE PROGRAM ADMINISTRATOR A copy of the form must also be sent to the dialysis facility providing support services and to the supplier if the beneficiary chooses Method II. Form CMS-382 (01/05) EF 02/2005 1 INSTRUCTIONS FOR COMPLETING THE ESRD BENEFICIARY SELECTION FORM METHOD CHANGES – Once you have made your initial selection, your reimbursement must be handled in that manner until December 31 of the year in which you signed the ESRD Beneficiary Selection form. If you wish to continue your initial selection beyond December 31, you do NOT complete another ESRD Beneficiary Selection form. You will automatically continue to have your reimbursement handled in the manner you selected. If you do not wish to continue with your initial selection beyond December 31, you MUST complete another ESRD Beneficiary Selection form. This subsequent form must be signed, dated and This form is to be filled out only by Medicare postmarked PRIOR to January 1 of the year you wish beneficiaries dialyzing at home and not by Medicare your selection change to be effective. This is the only beneficiaries who are currently dialyzing in a facility. way changes are made, and this is the only reason you should ever complete more than one ESRD Your selection of either Method I or Method II in no Beneficiary Selection form. way inhibits your return to incenter treatment or selection for any other treatment options should that be necessary. PRIVACY ACT STATEMENT METHOD I – The first method is for your dialysis As required by 5 U.S.C. 552a (the Privacy Act of facility to assume the responsibility for your care. Under this method, the facility is required to provide 1974), you are advised that the Centers for Medicare & Medicaid Services is authorized to collect the data to you any and all dialysis equipment, supplies and on this form by Section 1881(b)(1) of the Social home support services that you need to dialyze at home. It also is required to order, store, deliver, and Security Act and 42 CFR 405.544. The purpose for pay the manufacturers and suppliers for these items. collecting this information is stated above. Your Under this arrangement you are responsible to your response to the questions on this form is not required dialysis facility for the Medicare Part B deductible by law. However, if you do not provide this informaand 20% coinsurance. tion, requests for end-stage renal dialysis reimbursement may be denied or delayed until it is provided. METHOD II – While your facility is responsible for You should be aware that the information you provide assuring that you receive all items and services that may be verified by a computer match (P.L. 100-503). you require for home dialysis, the second method allows you to deal directly with a single supplier for Individually identifiable patient information will not securing the necessary dialysis equipment and supplies. be disclosed except as provided for by the Privacy Act. Then your supplier bills the Medicare program for payment. Under this arrangement, you are responsible to the supplier for the Medicare Part B deductible and 20% coinsurance. Centers for Medicare & Medicaid Services regulations provide two (2) ways that a Medicare beneficiary dialyzing at home can choose to have the Medicare program pay for his/her dialysis care (exclusive of physician services). The purpose of the Beneficiary Selection form is for you, the beneficiary, to select the method that best suits your requirements. It is important you choose one of these two methods, complete and sign the form and return it to the dialysis facility that supervises your care as soon as possible. You must complete all sections of this form. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0372. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Form CMS-382 (01/05) EF 02/2005 2 Jurisdiction B DME MAC Supplier Manual Chapter 15: Pricing [MARCH 2007] 15 Pricing The Medicare Pricing Department is responsible for the accurate and appropriate calculation and implementation of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) prices. Note: The beneficiary’s permanent address, rather than the location of the DMEPOS supplier, will determine the amount allowed by Medicare for a particular service. There are three DMEPOS payment methodologies: Fee Schedules—applies to the allowed amount for inexpensive items, those items that require frequent and substantial servicing, other prosthetic and orthotic devices, capped rental items, and oxygen and oxygen supplies and parenteral and enteral nutrition (PEN). Fee schedule amounts are updated annually. Reasonable Charge—applies to the allowed amount for certain dialysis equipment and supplies and therapeutic shoes claims. Reasonable charge amounts are updated annually. Drug Pricing—applies to the allowed amount for immunotherapy, bronchodilator, and other drugs. Most fees determined under drug pricing are subject to quarterly updates. Note: Fee schedules can change as the result of Centers for Medicare & Medicaid Services (CMS) revisions and/or through the application of inherent reasonableness, which is a review to determine if the existing prices are appropriate. The factors used to determine inherent reasonableness include, but are not limited to, price markup, differences in charges, costs and utilization. FEE SCHEDULES Most payments of durable medical equipment (DME) are based on a fee schedule. A standard fee is established for each DMEPOS item by state. Payment is calculated using either the fee schedule amount or the actual charge submitted on the claim, whichever is lower. The fee schedule allowances include the application of national floors and ceilings. The DME fee schedules include items of DME as well as supplies needed to use the DME and are divided into the following categories: Inexpensive or other routinely purchased DME Items requiring frequent and substantial servicing Customized items Other prosthetic and orthotic devices Capped rental items Oxygen and oxygen equipment Surgical Dressings Parenteral and enteral nutrition (PEN) (effective January 1, 2002) Therapeutic shoes and Inserts (effective January 1, 2005) 1 Jurisdiction B DME MAC Supplier Manual Chapter 15: Pricing [MARCH 2007] For each class of equipment, payment is based on fees established effective January 1, 1989, and these fees are indexed annually. After application of the annual fee update for all categories of DME except prosthetics and orthotics, the national floor and ceiling payment limits are applied. Alaska and Hawaii are not subject to national floors and ceilings. Prosthetic and orthotic items and/or supplies are subject to regional limits. Payment for surgical dressing fees is an exception and is calculated using a 1992 base period. The Balanced Budget Act of 1997 section 4315 authorized the secretary to implement a fee schedule for parenteral and enteral nutrition (PEN) items and services. These items were previously paid on a reasonable charge basis. The new PEN fee schedule is effective for claims with dates of service on or after January 1, 2002. Gap Filling The fee schedule for items for which charge data is not available is calculated based on: Fee schedule amounts for comparable equipment Fee schedule amounts of other DME MACs, and Supplier price lists Where supplier price lists are used, efforts are made to obtain prices in effect during the base year (1986–1987). Mail order catalogs are often used as sources of price information. A deflation factor is applied if the price information is from a period other than the base period. This is done in order to approximate the base year price for gap filling purposes. The DMEPOS Fee Schedules can be located on the National Government Services, Inc. Web site at: www.adminastar.com/Providers/DMERC/FeeSchedule/DMERCPricing.htm. The DMEPOS Fee Schedules can also be located on the Centers for Medicare & Medicaid Services (CMS) Web site at: www.cms.hhs.gov/DMEPOSFeeSched/01_overview.asp. REASONABLE CHARGES The manner in which reasonable charge allowances by Medicare are determined is stipulated by Medicare law and not left to the discretion of the Medicare carrier. Medicare law specifically states that the amount allowed by Medicare must be the lowest of: The actual charge The supplier’s customary charge or the 50th percentile of arrayed and weighted customary charges in the absence of a customary charge for the specific service rendered The prevailing charge, or The Inflation-Indexed Charge (IIC) Data regarding suppliers’ fees is obtained by compiling information from claims that have been submitted. Records of all charges are kept on each claim processed during a calendar year. This information identifies the supplier, the type of service, the area in which the service was rendered, and the charge for that service. Effective with the 1995 reasonable charge updates, the data will be compiled using beneficiaries’ state of residency, rather than the area from which the service was rendered. 2 Jurisdiction B DME MAC Supplier Manual Chapter 15: Pricing [MARCH 2007] Beginning January of each year, the data accumulated from July 1st of the second preceding year through June 30th of the preceding year is arrayed to develop the current year’s Annual Pricing Update of Medicare allowances. For example, data accumulated from July 1, 1999, to June 30, 2000, is arrayed to develop the Annual Pricing Update of Medicare allowances for 2001. The annual update reflects the changes in the fees most frequently charged by suppliers for a particular service, within a specific locality, during the 12-month period ending June 30th of the previous year. This time frame is referred to as the base year. The customary and reasonable charge effective for the new annual pricing update does not necessarily reflect the fees currently being charged. Customary Charges The customary charge is the charge that best represents the most frequently charged amount by a supplier for a particular service. In order to determine the customary charges for each individual supplier, the actual charges the supplier has submitted for services rendered during the year ending June 30th immediately preceding the start of the Annual Pricing Update (January of each year) for a given service, are arrayed in ascending order and the median charge is calculated. If you do not have at least three charges for a procedure code, then the 50th percentile of all other suppliers’ customary charges weighted by frequency will be used as the customary charge. The lowest actual charge, which is high enough to include the median of the arrayed charge data, is then selected as the suppliers’ customary charge for the service. For example, if ABC supplier charges $12 for a particular service 75 times during a calendar year and $15 twelve times for the same service, $12 would best represent the actual charge made by that supplier. The following is an example of how charges for a supplier would be arrayed in order to determine the customary charge. Charge $10.00 $12.50 $14.00 $15.00 Frequency Billing 20 times 40 times 35 times 5 times Cumulative Frequency 20 60 95 100 Based on the cumulative frequency of 100 submitted charges, the median charge would be the 50th charge. In this example, the median charge submitted is $12.50. There must be at least three (3) billed charges for the same procedure by the same supplier to establish a customary for that procedure within the base year. Prevailing Charges The prevailing charge is the 75th percentile of all suppliers’ customary charges, within the beneficiary state for a specific service or procedure, weighted by frequency. Prevailing charges are calculated in much the same way as customary charges. The customary charge for each procedure is arrayed in ascending order, and weighted by how often the supplier rendered the services as reflected by the data used to calculate the customary charge. The prevailing charge is established at the 75th percentile of these cumulative services. There must be at least four customary charges for a given procedure to establish a prevailing charge for that service. 3 Jurisdiction B DME MAC Supplier Manual Chapter 15: Pricing [MARCH 2007] The proper procedure for establishing prevailing charges is illustrated in the following example: Number of Supplies Rendered by Suppliers Customary Charge $5.00 $6.00 $7.00 $8.00 Total with Customary Charges as Indicated 27 30 25 18 100 Cumulative Services 27 57 82 100 In this example, 75 percent of the total of 100 supplies falls at the 75th supply. The 75th supply falls within the cumulative frequency of 82 submitted supplies; therefore $7 becomes the prevailing charge. Inflation-Indexed Charge for Nonphysician Services The inflation-indexed charge (IIC) is the lowest of the reasonable charges for the previous Annual Pricing Update year updated by an inflation index factor. [The inflation index factor is based on the change in the Consumer Price Index (CPI).] The reasonable charges include the prevailing charge, customary charge, lowest charge level (if applicable), and the IIC. The IIC calculation does not take into account any reasonable charge limitation resulting from the application of comparability, inherent reasonableness or the 50th percentile in the absence of a customary charge. Lowest Charge Level The lowest charge level (LCL) is calculated the same way that the prevailing charge is, except that the LCL is based on the data derived from claims processed during the preceding months of July through September prior to the annual fee screen pricing update. The charge at the 25th percentile is selected as the LCL prevailing. LCL calculations must be derived based on at least 20 charges for an item and no less than four suppliers within the locality. Note: The only charges subject to the LCL limitations are PEN services. DRUG PRICING The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MPDIMA), changed the basis for payment of drugs and biologicals not paid on a cost or prospective payment basis. The different instructions for 2004 and 2005 dates of service are listed below. Effective January 1, 2005, drugs and biologicals not paid on a cost or prospective payment basis will be paid based on the new Average Sale Price (ASP) drug payment system. The new payment system is based on quarterly data submitted to CMS by manufacturers. CMS will supply contractors with the ASP drug pricing files for Medicare Part B/DME MAC drugs on a quarterly basis. Beginning January 1, 2005, the payment allowance limits for Medicare Part B/DME MAC drugs and biologicals that are not paid on a cost or prospective payment basis are 106 percent of the ASP. CMS will update the payment allowance limits quarterly. There are exceptions to this general rule as summarized below. 4 Jurisdiction B DME MAC Supplier Manual Chapter 15: Pricing [MARCH 2007] The payment allowance limits for infusion drugs furnished through a covered item of durable medical equipment on or after January 1, 2005 will continue to be 95 percent of the AWP reflected in the published compendia as of October 1, 2003 regardless of whether or not the durable medical equipment is implanted. The payment allowance limits will not be updated in 2005. The payment allowance limits for drugs not included in the ASP Medicare Part B Drug Pricing File are based on the published wholesale acquisition cost (WAC) or invoice pricing. Effective for January 1, 2004–December 31, 2004, payments for drugs billed to the DME MACs are based on 85 percent of the AWP for HCPCS payment amounts based on the April 1, 2003, AWP fees. Exceptions to this calculation are as follows: The payment limits for infusion drugs furnished through an item of durable medical equipment on or after January 1, 2004, will be 95 percent of the October 1, 2003 AWP. The payment limits for new drugs or biologicals will be 95 percent of the AWP. A new drug is defined as an unlisted drug (not currently covered by a HCPCS code) that was FDA approved subsequent to April 1, 2003. A drug would not be considered new if: The brand or manufacturer of the drug changed; a new formulation of the vial size is developed; or the drug received a new indication. The payment limits for certain drugs studied by the Office of the Inspector General and Government Accounting Office are based on the percentages of the April 1, 2003 AWPs specified on Table 1 in the CMS Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, chapter 17, section 20. Payment limits determined under this instruction shall not be updated during 2004. Written requests for ASP fees or reasonable charge fees (prevailing [per state] fees) or customary fees (individual supplier’s fees) can be sent to the following address: Freedom of Information (FOI) P.O. Box 50454 Indianapolis, Indiana 46250-0454 INDIVIDUAL CONSIDERATION Unusual services and items are generally reported to the carrier with miscellaneous HCPCS codes. It will be necessary in these situations for the supplier to furnish documentation describing the service or item, manufacturer name, product name and number and the suggested retail price. When necessary, consultants’ advice will be obtained. INHERENT REASONABLENESS Where a review of customary and prevailing fees indicates excessive or deficient amounts, applying inherent reasonableness may be appropriate. We will always publish notice of proposed inherent reasonableness charges and provide a minimum of a 30-day comment period. This notice will include the HCPCS code, the current prevailing charge and the proposed charge. We will also include source documentation that supports the proposed charge. After comments are reviewed, we will publish a final decision and responses to the issues raised in the comments. 5 Jurisdiction B DME MAC Supplier Manual Chapter 16: Medicare Benefit and Denial Categories [MARCH 2008] 16 Medicare Benefit and Denial Categories BENEFIT CATEGORIES Medicare Part B covered services processed by the durable medical equipment Medicare administrative contractor (DME MAC) fall into benefit categories as specified by the Social Security Act (the Act). These benefit categories include: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) Durable medical equipment (DME) Prosthetic devices Braces (orthoses) Arm prostheses Leg prostheses Eye prostheses Home dialysis supplies and equipment Surgical dressings Immunosuppressive drugs Erythropoietin for home dialysis patients Therapeutic shoes for diabetics Oral anticancer drugs Oral antiemetic drugs (replacement for intravenous antiemetics) Intravenous immune globulin for primary immunodeficiency Some general definitions and coverage issues relating to DME, prosthetic devices and braces are listed below. Detailed information relating to specific items may be found in each individual medical policy. There are multiple individual policies for items described by benefit categories 1–3. Items described by benefit categories 5–13 each have a unique medical policy. Refer to those policies for information on definitions and coverage and payment rules. Durable Medical Equipment Durable medical equipment is equipment which; (a) can withstand repeated use, and (b) is primarily and customarily used to serve a medical purpose, and (c) generally is not useful to a person in the absence of an illness or injury, and (d) is appropriate for use in the home. Supplies and accessories which are required for the effective use of medically necessary durable medical equipment are covered. Supplies may include drugs and biologicals, which must be put directly into DME (e.g., nebulizers, infusion pumps) in order to achieve the therapeutic benefit of equipment. Medically necessary repairs, skilled maintenance and replacement of medically necessary durable medical equipment are covered. Refer to individual policies for specific information on definitions and coverage and payment rules. 1 Jurisdiction B DME MAC Supplier Manual Chapter 16: Medicare Benefit and Denial Categories [MARCH 2008] Home Use of Durable Medical Equipment Medicare law limits Part B payment for DME items/services used (delivered) in the patient’s home. If a hospital is a participating hospital, and emergency hospital or a hospital which meets the requirements of Section 1861(e)(1) of the Act, it does not qualify as the patient’s home. The following apply when the individual is in a skilled nursing facility (SNF): Where an institution is classified as a participating SNF, a Section 1819(a)(1) institution (i.e., an institution primarily engaged in providing skilled nursing care and related services or rehabilitation services for the rehabilitation of injured, disabled or sick persons, and is not primarily for the care and treatment of mental diseases), or where a SNF has a part classified as participating and part classified as meeting Section 1819(a)(1) of the Act, it cannot be considered the individual’s home. If an institution has a part which is participating or a part which meets Section 1819(a)(1), and a remaining part which does not meet Section 1819(a)(1), the institution may be considered the individual’s home only if he/she was in the part which does not meet Section 1819(a)(1) of the Act. If a DME rental start date coincides with the patient’s discharge date from an institution not classified as a “home,” DME MACs pay for medically necessary DME. Note: These rules apply only to DME claims. Orthotic and prosthetic devices are not subject to the “home use” requirement for coverage and payment purposes. Definition of Beneficiary’s Home for DME Purchase or Rental Reference: Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 (Covered Medical and Other Health Services), Section 110.1.d. For purposes of rental and purchase of DME, a beneficiary’s home may be his/her own dwelling, an apartment, a relative’s home, a home for the aged, or some other type of institution. However, an institution may not be considered a beneficiary’s home if it: meets at least the basic requirement in the definition of a hospital, i.e., it is primarily engaged in providing by or under the supervision of physicians, to inpatients, diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, and sick persons, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons; or meets at least the basic requirement in the definition of a skilled nursing facility, i.e., it is primarily engaged in providing to inpatients skilled nursing care and related services for patients who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons. Thus, if an individual is a patient in an institution or distinct part of an institution which provides the services described in the bullets above, the individual is not entitled to have separate Part B payment made for rental or purchase of DME. This is because such an institution may not be considered the individual’s home. The same concept applies even if the patient resides in a bed or portion of the institution not certified for Medicare. 2 Jurisdiction B DME MAC Supplier Manual Chapter 16: Medicare Benefit and Denial Categories [MARCH 2008] If the patient is at home for part of a month and, for part of the same month is in an institution that cannot qualify as his or her home, or is outside the U.S., monthly payments may be made for the entire month. Similarly, if DME is returned to the provider before the end of a payment month because the beneficiary died in that month or because the equipment became unnecessary in that month, payment may be made for the entire month. Prosthetic Devices Prosthetic devices are items that replace all or part of an internal body organ or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ. The test of permanence is considered met if the medical record, including the judgment of the attending physician, indicates that the condition is of long and indefinite duration. Coverage under this benefit includes, but is not limited to, the following: Breast prostheses Facial prostheses Parenteral and enteral nutrition Ostomy supplies Urological supplies in patients with permanent urinary incontinence, and Glasses or contact lenses in patients with aphakia or pseudophakia Medically necessary supplies that are required for the effective use of a medically necessary prosthetic device are covered. Nutrients that are administered through repairs, adjustments and replacement of medically necessary prosthetic devices are covered. Refer to individual policies for specific information on definitions and coverage and payment rules. Dental prostheses (i.e., dentures) are excluded from coverage. Claims for internal prostheses (e.g., intraoral devices, intraocular lenses, joint implants, etc.) are not processed by the DME MAC. Braces (Orthoses) A brace is a rigid or semi-rigid device, which is used for the purpose of supporting a weak or deformed body member, or restricting or eliminating motion in a diseased or injured part of the body. Medically necessary repairs and replacement of medically necessary braces are covered. DENIAL CATEGORIES The Medicare program provides coverage for a wide range of services that improve the health of the elderly and disabled. Medicare, however, does not cover every service that is related to the health care of its beneficiaries. Coverage and exclusion of services are defined in the Act, which in turn are implemented through federal regulations, Medicare manuals, instructions from the Centers for Medicare & Medicaid Services (CMS) and decisions by the individual DME MACs that administer the Medicare program in each jurisdiction. 3 Jurisdiction B DME MAC Supplier Manual Chapter 16: Medicare Benefit and Denial Categories [MARCH 2008] This section provides an overview of the denial categories for services billed to Medicare. It is important to understand the basic concepts for proper submission and to understand supplier and beneficiary liability issues. The Medicare program is complex and there are occasional exceptions to some of the statements made below. Special coverage guidelines are published in the individual medical policies, which can be found on the National Government Services Web site at www.adminastar.com/Providers/DMERC/MedicalPolicy/MedicalPolicy.cfm and the quarterly Jurisdiction B Connections. Section 1861(s) of the Act defines the medical and other health services that are covered by Medicare. Services that are not included in the benefit category definitions are considered benefit category denials. While these services are often reasonable and important health care services, they are just not included in the benefit package specified by the law. Examples (not all-inclusive) of items in this category include: 1) Disposable supplies other than surgical dressings or supplies required for the effective use of DME or prosthetic devices 2) Equipment that does not serve an exclusively medically therapeutic function 3) Most oral and injectable medications Note: Denials for this reason are described by the term “noncovered” in the Medical Policy Information chapter. Medical Necessity Denials Section 1862(a)(1) of the Act excludes services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” CMS issues national coverage determinations (NCDs) that are binding on all Medicare carrier jurisdictions. In addition, the DME MAC has the authority and responsibility to make medical necessity determinations on all aspects of medical practice not defined nationally. Services that are considered investigational or experimental are denied under this exclusion. Preventative services are excluded from coverage under this section of the Act because they do not diagnose or treat an established condition (not because they are inherently unreasonable or unnecessary). Note: Denials under this provision of the law are described by the term “not medically necessary” in the Medical Policy Information chapter. Other Statutory Exclusion Denials Sections 1862(a)(2)–1862(a)(16) of the Act list other categories of services that are excluded from coverage by Medicare. Those that may be related to durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items are as follows: A) Routine services and appliances (Section 1862[a][7]). Some examples of items excluded from coverage under this section are: 1) Eyeglasses and contact lenses except in those patients who have had cataract extraction or have had their lens removed for other indications 2) Hearing aids 4 Jurisdiction B DME MAC Supplier Manual Chapter 16: Medicare Benefit and Denial Categories [MARCH 2008] B) Orthopedic shoes or other supportive devices for the feet. An exception is a shoe that is an integral part of a leg brace. Another exception is a special shoe and inserts used for the prevention or management of foot ulcers in diabetics. C) Personal comfort items. D) Services received outside of the United States. E) Services for which another government program is primary (e.g., Veteran’s Administration). F) Services provided to an immediate relative or members of the household. G) Services relating to war injuries received after the beneficiary is eligible for Medicare coverage. H) Services for which the beneficiary has no legal obligation to pay. I) Services paid under Workers’ Compensation. Note: Denials for these reasons are described as “noncovered” in the Medical Policy Information chapter. Fragmented Coding The Medicare allowance for an individual Healthcare Common Procedure Coding System (HCPCS) code often includes several component items. An individual HCPCS code will be denied if it is determined that the item described by that code is included in the allowance for another code that has also been billed. In this case, even though the item provided may be covered—the payment for the code is being denied. Note: Denials for this reason will be described as “not separately payable” in the Medical Policy chapter. Other Denials Duplicate Claims If a claim is received for a service that has been previously processed, and a Medicare allowed amount has been established, the second claim will be denied as a duplicate. Incomplete Claims Suppliers are required to submit completed CMS-1500 claim forms, or the most current version of American National Standards Institute (ANSI) and/or National Council for Prescription Drug Programs (NCPDP) electronic formats, for items provided to Medicare beneficiaries. Claims lacking beneficiary information, diagnosis coding (where necessary), procedure coding, ordering physician’s name and National Provider Identifier (NPI) or billing supplier information will be denied as incomplete claims. However, these claims will be considered for payment when the missing information is supplied. Reduction to the Least Costly Alternative In certain circumstances, the DME MAC may determine that the item that was provided and billed contains either deluxe features or a feature of a medical nature not required by the patient’s condition. If there is a medically appropriate alternative item that is less costly than the item furnished, the amount paid will be based on the allowance for the item that meets the patient’s medical needs. This will result in a payment reduction rather than a complete denial. 5 Jurisdiction B DME MAC Supplier Manual Chapter 16: Medicare Benefit and Denial Categories [MARCH 2008] PREVENTION OF COMMON CLAIM SUBMISSION ERRORS The following chart identifies the most common claim submission errors, as well as helpful tips on how to decrease the number of errors. Note that suppliers should always refer to their remittance advice to determine the ANSI code assigned to the service line. ANSI codes are used to convey appeals information and other claim-specific information, providing additional explanation for claim-level adjustments. ANSI Code CO-18 CO-151 OA-109 CO-16 CO-176 CO-173 PR-13 CO-22 PR-31 PR-27 Category Duplicate claim Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day’s supply. Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. Claim/service lacks information which is needed for adjudication. Payment denied because the prescription is not current. Payment adjusted because this service was not prescribed by a physician. The date of death precedes the date of service. Payment adjusted because this care may be covered by another payer per coordination of benefits. Claim denied as patient cannot be identified as our insured. Expenses incurred after coverage terminated. Denial Type Duplicate Same/similar Jurisdiction Return/Reject Return/Reject Return/Reject Eligibility MSP Eligibility Eligibility ANSI Reason Code CO-18 Definition: Duplicate claims Prevention Tips: The Jurisdiction B DME MAC receives a large quantity of claims that result in duplicate denials. The duplicate claim submission is the number one claims submission error. Generally, claim submission errors are services/items previously processed for the same patient, date of service and/or HCPCS code. Suppliers are reminded to allow 14 days for electronically submitted claims and 29 days for hard-copy claims before resubmitting a claim to the DME MAC. Suppliers should utilize the Claim Status Inquiry (CSI) or Interactive Voice Response (IVR) Unit at 877-299-7900 before resubmitting the claim for payment. If a supplier has documentation to support that the services are not actual duplicate services, but rather, medically necessary services that are in addition to the services submitted on the initial claim and should be paid by Medicare, the supplier may submit an appeal request along with documentation to support medical necessity. If the reason for denial was due to a minor error or omission, the supplier may use the reopening process rather than filing an appeal. Refer to Chapter 19 of the Jurisdiction B DME MAC Supplier Manual for reopening criteria. ANSI Reason Code CO-151 Definition: Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day’s supply. 6 Jurisdiction B DME MAC Supplier Manual Chapter 16: Medicare Benefit and Denial Categories [MARCH 2008] Prevention Tips: Suppliers should determine the patient’s history during the intake process to determine if same or similar equipment was previously obtained. As an additional resource for this information, suppliers may utilize the IVR Unit to obtain same/similar information. If a claim denies because the patient has previously received same/similar equipment and the supplier was unaware of the previous purchase, the supplier should refund the beneficiary or exercise his/her appeal rights and request a redetermination. Redetermination requests should be submitted to the following address: Redeterminations P.O. Box 6036 Indianapolis, Indiana 46206-6036 ANSI Reason Code OA-109 Definition: Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. Prevention Tips: National Government Services is the Jurisdiction B DME MAC that processes DMEPOS claims for the states of Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin. DMEPOS jurisdiction is based on the beneficiaries address on file with the Social Security Administration. Claims submitted to an incorrect DME MAC jurisdiction will receive this type of denial. Suppliers should verify that the address you are using on the claim for the beneficiary is the same address on file with Social Security Administration (SSA). This will help to ensure claims are sent to the correct DME MAC jurisdiction for processing. Claims received at the Jurisdiction B DME MAC via electronic submission for a beneficiary who resides in another Jurisdiction, will be automatically transferred to the appropriate DME MAC based on the beneficiary’s address submitted on the claim. A transferred claim will not be processed by the DME MAC Jurisdiction that received the transferred claim, unless the supplier has a signed EDI enrollment form on file with that Jurisdiction. Claims received at the Jurisdiction B DME MAC via electronic submission for a beneficiary who resides in Jurisdiction B, will enter the processing system once accepted on the front end. If within the processing system, it is determined that the address is incorrect and the beneficiary actually resides outside of Jurisdiction B, the claims will be denied with this type of denial. 1st Example: An electronic claim is submitted to Jurisdiction B for John Doe in Virginia (VA). John Doe’s address with SSA is Florida (FL). The claim passes the front-end and enters the processing system. Since John Doe's address with SSA is FL, the claim will be denied with OA-109. The supplier may resubmit the claim with the correct address of FL to Jurisdiction B. When the electronic claim is submitted with the FL address to Jurisdiction B, it will be transferred to Jurisdiction C. The supplier will need to have an EDI enrollment form on file with Jurisdiction C for them to accept that claim electronically. Suppliers may also choose to bill that claim directly to Jurisdiction C, since the beneficiary resides in that Jurisdiction. 7 Jurisdiction B DME MAC Supplier Manual Chapter 16: Medicare Benefit and Denial Categories [MARCH 2008] 2nd Example: An electronic claim submitted to Jurisdiction B for John Doe in Florida (FL). John Doe's address with SSA is FL. The electronic claim will be automatically transferred to Jurisdiction C and will not enter the Jurisdiction B processing system. The supplier will need to have an EDI enrollment form on file with Jurisdiction C for them to accept that claim electronically. Suppliers may also choose to bill that claim directly to Jurisdiction C, since the beneficiary resides in that Jurisdiction. ANSI Reason Code CO-16 Definition: Claim/service lacks information which is needed for adjudication. Prevention Tips: Claims were submitted to the Jurisdiction B DME MAC that contained incomplete or invalid information and cannot be processed as submitted. Refer to the Remark Code (REM) located on the far-left side of the standard paper remittance (SPR) advice. The REM advises what information is missing or incomplete on the claim. Resubmit a new claim with the missing/incomplete information. ANSI Reason Code CO-176 Definition: Payment denied because the prescription is not current. Prevention Tips: The Jurisdiction B DME MAC encourages suppliers to review the medical policies to verify whether or not an initial, revised or recertification Certificate of Medical Necessity (CMN) is required. When submitting claims that require a CMN, suppliers should ensure that all sections of the CMN are completed prior to claim submission to the DME MAC. Suppliers should submit the CMN with initial claim only and wait 24–48 hours before submitting any subsequent claims. The medical policies are located on the National Government Services Web site at www.adminastar.com/Providers/DMERC/MedicalPolicy/MedicalPolicy.cfm. ANSI Reason Code CO-173 Definition: Payment adjusted because this service was not prescribed by a physician. Prevention Tips: The Jurisdiction B DME MAC encourages suppliers to review medical policies to verify whether or not the items or services routinely provided to Medicare beneficiaries require an initial, revised or recertification CMN. When submitting claims that require a CMN, suppliers should ensure that all sections of the CMN are completed prior to submitting the claim to the DME MAC. Suppliers should submit the CMN with the initial claim only and wait 24–48 hours before submitting any subsequent claims. The medical policies are located on the National Government Services Web site at www.adminastar.com/Providers/DMERC/MedicalPolicy/MedicalPolicy.cfm. ANSI Reason Code CO-13 Definition: The date of death precedes the date of service. Prevention Tips: Medicare Part B coverage was not valid when the patient received this item and/or service. This means that expenses were incurred under on of the following circumstances: After coverage was terminated Prior to coverage 8 Jurisdiction B DME MAC Supplier Manual Chapter 16: Medicare Benefit and Denial Categories [MARCH 2008] The date of death precedes the date of service, or Medicare was unable to identify the patient as an insurer Suppliers should check the patient records for valid coverage dates and for correct patient information prior to claim submission. Suppliers may resubmit claims denied in error only after the beneficiary’s record has been updated with the correct information. ANSI Reason Code CO-22 Definition: Payment adjusted because this care may be covered by another payer per coordination of benefits. Prevention Tips: The Jurisdiction B DME MAC records indicate that Medicare is the secondary payer. Suppliers must send the claim to the correct payer/contractor first and then submit the claim to Medicare with a copy of the primary payment notice. When claims are submitted to Medicare as primary and another insurer is actually the primary payer, claims will be denied and suppliers will receive the following denial message: “Our records show that Medicare is your secondary payer. This claim must be sent to your primary insurer first. Resubmit this claim with a copy of the primary payment notice.” Suppliers who receive this edit must send the claims to the correct payer/contractor first and then resubmit the claim to Medicare with a copy of the primary payment notice or the Explanation of Benefits. If the beneficiary’s record/control file at the Common Working File (CWF) contains incorrect or outdated payer information, which has caused the claim to deny for the above mentioned reason, the supplier should advise the beneficiary to contact the Coordination of Benefits Contractor toll free at 800-999-1118 to have their Medicare Secondary Payer control file updated. The supplier should resubmit the claim only after the payer information on the beneficiary’s record has been updated to reflect the correct payer information. ANSI Reason Code PR-31 Definition: Claim denied as patient cannot be identified as our insured. Prevention Tips: Medicare Part B coverage was not valid when the patient received this item and/or service. This means that expenses were incurred under on of the following circumstances: After coverage was terminated Prior to coverage The date of death precedes the date of service, or Medicare was unable to identify the patient as an insurer Suppliers should check the patient records for valid coverage dates and for correct patient information prior to claim submission. Suppliers may resubmit claims denied in error, only after the beneficiary’s record has been updated with the correct information. 9 Jurisdiction B DME MAC Supplier Manual Chapter 16: Medicare Benefit and Denial Categories [MARCH 2008] ANSI Reason Code PR-27 Definition: Expenses incurred after coverage terminated. Prevention Tips: Medicare Part B coverage was not valid when the patient received this item and/or service. Expenses incurred after coverage was terminated, prior to coverage, or Medicare was unable to identify the patient as an insurer. Suppliers should check the patient records for valid coverage dates and for correct patient information prior to claim submission. Suppliers should utilize the CSI or the IVR Unit at 877-299-7900 to validate patient eligibility. To find out more about CSI, visit the National Government Services Web site at www.NGSMedicare.com: Select Select Select Select Select AdminaStar Federal Providers & Other Partners Electronic Data Interchange (EDI) DME MAC Information Overview of EDI Products and Services 10 Jurisdiction B DME MAC Supplier Manual Chapter 17: Supplier Remittance Notice [MARCH 2007] 17 Supplier Remittance Notice GENERAL INFORMATION Once a claim has completed processing through the Medicare system, a supplier remittance notice is generated for all suppliers for all claims, whether they file paper or electronic claims. For those suppliers that file nonassigned claims, a supplier remittance notice will be sent and the beneficiary will receive notice of adjudication on nonassigned claims in the form of the Medicare Summary Notice (MSN). The supplier remittance notice includes a list of all claims paid or denied during a particular payment period. Included with the supplier remittance notice is the Medicare check for those claims that are approved for payment. The standard paper remittance (SPR) notice is the product of the Centers for Medicare & Medicaid Services’ (CMS) standardization of provider/supplier payment notification. This remittance form was created to: Provide a new remittance notice that is uniform in both content and format; and Ease the transition to the electronic remittance notice media. As part of the effort to eliminate any variations in the administration of Medicare across the country, and to furnish a uniform level of information to all providers of health care about the decisions made on their claims, a standardized set of codes have been created to explain how a claim has been processed. Under the standard format, only codes approved by the American National Standards Institute (ANSI) insurance subcommittee, and Medicare-specific supplemental messages approved by CMS, may be used. ANSI is a nongovernmental association of which CMS is a member. TIPS FOR READING THE REMITTANCE NOTICE One claim is listed in each block of the remittance, and is separated from other claims with a line. Claims are listed in alphabetical order by patient’s last name. The columnar dollar amount fields for each line of the claim are totaled down and are displayed in the CLAIM TOTALS fields; these lines cannot be totaled across. ANSI Group, Reason, Remark and Medicare Outpatient Adjudication (MOA) codes are listed in the key at the end of the remittance notice. A TOTALS line that includes all claims on the remittance notice, as well as offsets and other adjustments, is located at the end of the suppler remittance notice. The net pay field on this line equals the amount of the check. Claim Control Numbers When claims are entered into the Medicare system, they are issued a tracking number known as a Claim Control Number (CCN) (also referred to as the Internal Control Number [ICN]). 1 Jurisdiction B DME MAC Supplier Manual Chapter 17: Supplier Remittance Notice [MARCH 2007] The first five digits of the 14-digit ICN/CCN indicate the date (in Julian date format) when Medicare received the claim. The Julian date is expressed by the first two digits being the year and the next three digits are the sequential numbering of the days of the year. The CCN/ICN also indicates whether the claim was submitted on paper or electronically or if it was electronically transferred from another durable medical equipment Medicare administrative contractor (DME MAC) jurisdiction (6th digit). Finally, the last digit of the CCN indicates if the claim is an initial claim or an adjusted claim. If the last digit is 1 or higher, the claim has been adjusted. ANSI and MOA Codes Medicare uses codes to explain the determination of a claim. All Medicare contractors are required to use ANSI codes. The DME MACs also use some Medicare specific codes called MOA codes. Each twodigit ANSI Reason code is preceded by one of the following three, two-letter ANSI group codes: PR = Patient responsibility; it indicates that the patient is financially responsible for the claim or claim line CO = Contractual obligation; it means that the supplier is financially responsible for the claim or claim line OA = Other adjustment The narrative description of each Remark code is given in the Glossary at the end of the supplier remittance notice. Note: Effective June 1, 2006, the CMS mandated the discontinuation of SPRs for suppliers that are set up to receive the electronic remittance advice (ERA). As a result, suppliers receiving the ERA will no longer receive the SPR 45 days after the ERA activation, and must rely solely on downloading the ERA files. This is true whether the ERA is received directly or through a billing agent, clearinghouse or other entity representing the supplier’s company. For more information on the suppression of SPRs, refer to CMS Medicare Learning Network Matters article MM4376 at www.cms.hhs.gov/MLNMattersArticles/downloads/MM4376.pdf. 2 Jurisdiction B DME MAC Supplier Manual Chapter 17: Supplier Remittance Notice [MARCH 2007] SAMPLE REMITTANCE NOTICE 3 Jurisdiction B DME MAC Supplier Manual Chapter 17: Supplier Remittance Notice [MARCH 2007] REMITTANCE NOTICE KEY Field Description PROVIDER NAME AND ADDRESS The name and address of the billing supplier. PROVIDER NUMBER The supplier number of the billing supplier and the number used to process the claims listed. PAGE NUMBER This field lists the current page number and the total number of pages of the remittance notice. DATE The date the remittance notice was generated. This date is the same as the date on the check. CHECK/EFT # The number in this field corresponds to the number on the check (if issued). The EFT # is the bank tracer number. STATEMENT # System generated number for tracking. PROVIDER BULLETIN This field is reserved for a general notice that is published to all suppliers on each remittance notice. PERF PROV The supplier number of the performing supplier. SERV DATE Service date as submitted on the claim. The lines within each claim are in descending order by the service date. POS Place of Service as billed on the claim. NOS Number (or units) of services as billed on the claim. PROC The HCPCS procedure code as submitted on the claim. If we change the code during processing, the billed code is listed below the approved code. MODS HCPCS modifiers which were submitted on the claim. BILLED The supplier’s submitted charge. ALLOWED The Medicare allowed amount prior to any deductions or offsets. DEDUCT The portion of the Medicare allowed amount that was applied to the patient's deductible. Remittance Notice Header: Individual Claim Summary: 4 Jurisdiction B DME MAC Supplier Manual Chapter 17: Supplier Remittance Notice [MARCH 2007] Field COINS Description The 20 percent coinsurance (based off the allowed amount after deductible) which is due by the patient. PROV PD The amount Medicare is paying to the supplier. RC-AMT The Adjustment Reason Code amount. These amounts are deducted from claim payment and do not include the deductible and coinsurance due by the patient. If there is more than one code, additional adjustment codes and remarks appear on the next line. NAME The patient’s name on the claim. HIC The patient’s Medicare number. AC The patient’s account number that has been assigned by the supplier. This number is listed when submitted on an electronic claim. ICN Internal Control Number. The CCN assigned to the claim in Julian date form. ASG The assignment value of the claim. “Y” indicates the claim is assigned, “N” means the claim is nonassigned. MOA Medicare Outpatient Adjudication Remark code. Up to five codes per line item may appear. These codes define the processing action taken on the line item of the claim. REM Remark Codes. Additional information regarding the claim. PT RESP Patient responsibility. This column will include amounts for noncovered services, deductible and coinsurance. CLAIM TOTALS This is the claim total line for each column. ADJUSTMENTS Adjustments that are made to the allowed amount for each individual claim and affect the total net. NET Net amount paid for individual claim. REMITTANCE TOTALS The net amount of the supplier’s check. The net amount is determined by: Total Remittance Summary: 5 Claim Total Allowed Amount Deductible Coinsurance Reason Code Amounts Previous Paid Interest Other dollar amounts Jurisdiction B DME MAC Supplier Manual Chapter 17: Supplier Remittance Notice [MARCH 2007] Field ADJS Description Adjustments which are made to the allowed amount and affect the total net. These include the fields below. PREV PD On adjusted claims, this is the amount previously paid on the original claim. PD TO PATIENT Paid to patient. When the patient has paid the supplier more than the applicable coinsurance and deductible, that overpayment is refunded to the patient from the supplier’s payment. INT Interest that has accrued because a clean claim did not complete processing within 30 days. MSP The amount paid by the primary insurer for Medicare Secondary Payer (MSP) claims. OTHER Other adjustments to the supplier’s payment. These could include a reduction due to overpayment recovery offset, a waiver offset, or IRS withholdings. OFFSET The Financial Control Number (FCN), Health Insurance Claim Number (HICN) and dollar amount regarding offset. CODES Detailed information defining the codes. Glossary: RESOURCES CMS Web-based Training: Understanding the Remittance Advice for Professional Providers; www.cms.hhs.gov/MLNproducts 6 Jurisdiction B DME MAC Supplier Manual Chapter 18: Medicare Summary Notice [MARCH 2007] 18 Medicare Summary Notice A Medicare Summary Notice (MSN) is sent to Medicare beneficiaries for each claim that is processed. On nonassigned claims, the MSNs are issued as the claims are processed. On assigned claims, the patient's MSN forms are mailed in 30-day cycles. Even though the supplier may have received notification of payment, the patient may not have received their MSN. Refer to the sample MSN on the following pages, as well as the corresponding details of the various numbered fields following the sample notice. 1 Jurisdiction B DME MAC Supplier Manual Chapter 18: Medicare Summary Notice [MARCH 2007] SAMPLE MSN 2 Jurisdiction B DME MAC Supplier Manual Chapter 18: Medicare Summary Notice [MARCH 2007] 3 Jurisdiction B DME MAC Supplier Manual Chapter 18: Medicare Summary Notice [MARCH 2007] SUMMARY OF NUMBERED FIELDS ON SAMPLE MSN 1) Date: Date the MSN was sent. 2) Customer Service Information: Who to contact with questions about the MSN. Provide your Medicare number (3), the date of the MSN (1), and the date of the service you have a question about (7). 3) Medicare Number: The number on your Medicare card. 4) Name and Address: If incorrect, contact the company listed in (2), and the Social Security Administration immediately. 5) Be Informed: Messages about ways to protect yourself and Medicare from fraud and abuse. 6) Part B Medical Insurance – Assigned Claims: Type of service. See the back of MSN for information about assignment. (Note: For unassigned services, this section is called “Part B Medical Insurance – Unassigned Claims.”) 7) Dates of Service: Date service or supply was received. You may use these dates to compare with the dates shown on the bill you receive from your doctor. 8) Claim Number: Number that identifies this specific claim. 9) Services Provided: Brief description of the service or supply received. 10) Amount Charged: Amount the provider billed Medicare. 11) Medicare Approved: Amount Medicare approves for this service or supply. 12) Medicare Paid Provider: Amount Medicare paid to the provider. (Please Note: For unassigned services, this column is called “Medicare Paid You.”) 13) You May Be Billed: The total amount the provider may bill you, including deductibles, coinsurance, and noncovered charges. Medicare supplement (Medigap) policies may pay all or part of this amount. 14) See Notes Section: If letter appears, refer to (16) for an explanation. 15) Provider’s Name and Address: Doctor (may show clinic, group, and/or referring doctor) or provider’s name and billing address. The referring doctor’s name may also be shown if the service was ordered or referred by another doctor. The address shown is the billing address, which may be different from where you received the services. 16) Notes Section: Explains letters in (14) for more detailed information about your claim. 17) Deductible Information: How much of your yearly deductible you have met. 4 Jurisdiction B DME MAC Supplier Manual Chapter 18: Medicare Summary Notice [MARCH 2007] 18) General Information: Important Medicare news and information. 19) Appeals Information: How and when to request an appeal. RESOURCES The Medicare & You national Medicare handbook provides more information about coverage and other services. For a free copy, call 1-800-MEDICARE (1-800-633-4227), TTY 877-486-2048. The “How To Read Your Medicare Summary Notice” booklet is available on the Medicare.gov Web site at www.medicare.gov/Publications/Pubs/pdf/11055.pdf. 5 Jurisdiction B DME MAC Supplier Manual Chapter 19: Reopenings and Appeals [MARCH 2008] 19 Reopenings and Appeals REOPENINGS FOR MINOR ERRORS AND OMISSIONS Where the supplier has made a minor error or omission in filing the claim, which in turn causes the claim to be denied, the supplier should not request a redetermination. In the case where a minor error or omission is involved, the supplier can request Medicare to reopen the claim so the error or omission can be corrected, rather than having to go through the appeal process. Suppliers can request a reopening for minor error or omissions either by telephone or in writing. Suppliers have one year to request a reopening from the date on the remittance notice. Examples of minor error or omissions include: Mathematical or computational mistakes Inaccurate data entry, or Denial of claims as duplicates which the supplier believes were incorrectly identified as a duplicate In situations where a provider, supplier or beneficiary requests a redetermination and the issue involves a minor error or omission, the durable medical equipment Medicare administrative contractor (DME MAC) will treat the request as a request for a reopening. In situations where a provider, supplier, or beneficiary requests a reopening and the issue does not involve a minor error or omission, the DME MAC will treat the request as a redetermination. Detailed instructions for submitting requests for reopenings for minor errors or omissions by telephone or in writing are provided below. Telephone Requests for Reopenings The DME MAC telephone reopening number is 317-841-1307. 1) Use the telephone reopening process to resolve minor errors or omissions involving: units of service; service dates; Healthcare Common Procedure Code System (HCPCS) coding; diagnosis codes and diagnosis reference; modifiers; place of service; and claims incorrectly denied as duplicate charges. 2) Suppliers should wait to call the telephone reopening line until they have received their Medicare remittance notice. No action can be taken until a final claim determination is issued. 1 Jurisdiction B DME MAC Supplier Manual Chapter 19: Reopenings and Appeals [MARCH 2008] 3) Suppliers should consult the Jurisdiction B DME MAC Supplier Manual and applicable medical policy guidelines before contacting the telephone reopening number. Failure to have the appropriate information available when contacting the telephone reopening line may result in an unfavorable decision. 4) Questions about the status of a claim or general Medicare payment and coding questions should not be directed through the telephone reopening line. Suppliers can obtain a claim status report through the Interactive Voice Response (IVR) Unit or by using Claim Status Inquiry (CSI). 5) The supplier must have the following information available before placing the call for a telephone reopening: Their Medicare supplier number The Medicare Claim Control Number (CCN) and reason for denial Beneficiary name and Medicare Health Insurance Claim Number (HICN) Any additional information to support why they believe the decision is not correct. This includes having the correct procedure code(s), modifier(s), diagnoses, units of service, etc. All medical information provided to the DME MAC must be documented in the patient’s file and available to the DME MAC should an audit be required. If a previous reopening decision has been issued, a redetermination must be made in writing. If a previous redetermination decision has been issued, a reconsideration must be filed. To effectively service all suppliers, each call will be limited to three claim issues. Written Requests for Reopenings Mail all written reopening requests to the following address: DME MAC Redeterminations P.O. Box 6036 Indianapolis, Indiana 46206-6036 Be sure to include the following information with the reopening request: The beneficiary’s name The beneficiary’s Medicare HICN The specific services(s) and/or item(s) for which the reopening is being requested and the specific date(s) of service, and The name and signature of the person filing the request Reopening requests for break in service issues, Certificate of Medical Necessity (CMN) extensions and other CMN changes are not permitted. These types of requests usually require a supplier to submit or fax copies of CMNs, delivery and pick-up information and other documentation before a final determination can be made; therefore, these must also be submitted as a redetermination request. 2 Jurisdiction B DME MAC Supplier Manual Chapter 19: Reopenings and Appeals [MARCH 2008] Phone counselors must devote significant time researching claim history and CMN status for these issues. This process would tie up incoming phone lines and create long waits for other suppliers attempting to use the telephone reopening lines. APPEALS Reference: Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 29 at www.cms.hhs.gov/manuals/downloads/clm104c29.pdf. Who May File an Appeal The Medicare program offers suppliers and beneficiaries the right to appeal claim determinations made by the carrier. The purpose of the appeals process is to ensure the correct adjudication of claims. Appeals activities conducted by Medicare carriers are governed by the CMS. Suppliers who provide services to Medicare Part B beneficiaries may appeal an initial claim reimbursement determination. Beneficiaries also have the right to appeal any claim determination. Additionally, a beneficiary may name another party to act on his/her behalf (appointed representative) to file an appeal, including a relative, friend, advocate, attorney, doctor or someone else. If the beneficiary appoints someone to act for him/her, the beneficiary and his/her appointed representative must sign, date and send us a statement naming the person acting on his/her behalf. Appeals Process and Time Limits for Filing Appeal The Medicare law consists of five possible appeal levels. The appellant must begin at the first level upon receipt of an initial determination. Each level of appeal, after the initial determination, has procedural steps that must be taken before the appeal can move to the next level. The following table summarizes the types of appeal, the order in which appeals must be followed and the filing requirements for each. Table 1: Summary of Appeal Levels, Filing Requirements and Time Limits Appeal Level Redetermination Reconsideration Administrative Law Judge (ALJ) Hearing Departmental Appeals Board (DAB) Review Federal Court (Judicial) Review Time Limit for Filing Request 120 days from the date of receipt of the initial determination 180 days from the date of receipt of the notice of the redetermination 60 days after the date of receipt of the reconsideration notice 60 days from the date of receipt of the ALJ decision/dismissal 60 days from the date of receipt of DAB decision or declination of review by DAB Where to File an Appeal Monetary Threshold Jurisdiction B DME MAC Redeterminations P.O. Box 6036 Indianapolis, Indiana 46206-6036 Qualified Independent Contractor (QIC) None HHS Office of Medicare Hearings and Appeals (OMHA) field office Prior to January 1, 2008, at least $110 remains in controversy DAB or ALJ Hearing Office None On or after January 1, 2008, at least $120 remains in controversy None Prior to January 1, 2008, at least $1,130 remains in controversy 3 Jurisdiction B DME MAC Supplier Manual Chapter 19: Reopenings and Appeals [MARCH 2008] Appeal Level Time Limit for Filing Request Where to File an Appeal Monetary Threshold On or after January 1, 2008, at least $1,180 remains in controversy Levels of Appeal Redeterminations The first level appeal is referred to as a redetermination. All redeterminations must be completed within 120 days of receipt. A party dissatisfied with an initial claim determination may request a redetermination. A redetermination is a second look at the claim and supporting documentation. If an initial determination on a claim has not been made, there are no appeal rights on that claim. Suppliers should wait to file a redetermination until they receive their Medicare remittance notice which provides the claim determination. A redetermination is a new, independent and critical re-examination of a claim. It is conducted by re-examining the information in the file and any additional documentation submitted with the request for a redetermination. The denial on a duplicate claim line item is not a denial of service. There are no appeal rights on the duplicate submission. Appeal requests on duplicate claim denials will be treated as inquiries—not as an appeal. The suppliers must request an appeal on the original denial (i.e., first claim submitted). The DME MAC will look at the first claim submission to determine whether the request was filed timely. The supplier may submit a fully completed Jurisdiction B DME MAC Request for Redetermination Form when requesting a redetermination. If this form is not used, the supplier’s request must contain all the following information: The beneficiary’s name The beneficiary’s Medicare HICN The specific services(s) and/or item(s) for which the reopening is being requested and the specific date(s) of service, and The name and signature of the person filing the request Incomplete requests will be dismissed with an explanation of the missing information. Suppliers will be instructed to resubmit the request with all of the missing information. When filing an appeal, a separate request is not required for each procedure code on the claim. All requests for a specific beneficiary or claim number can be combined on one request. Submit redetermination requests to the following address: Jurisdiction B DME MAC Redeterminations P.O. Box 6036 Indianapolis, Indiana 46206-6036 4 Jurisdiction B DME MAC Supplier Manual Chapter 19: Reopenings and Appeals [MARCH 2008] In situations where a provider, supplier or beneficiary requests a redetermination and the issue involves a minor error or omission, the DME MAC will treat the request as a request for a reopening. In situations where a provider, supplier, or beneficiary requests a reopening and the issue does not involve a minor error or omission, the DME MAC will treat the request as a redetermination. Reconsideration The second level of appeal is the reconsideration request. Section 1869 of the Social Security Act (the Act) entitles any individual dissatisfied with the contactor’s redetermination to file a request for reconsideration. This request must be submitted within 180 days of receipt of the redetermination. In accordance with Section 1869(c) of the Act, (the item or service has been deemed not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member) reconsiderations are to be processed within 60 days by entities called qualified independent contractors (QICs). When a claim is denied on the basis of Section 1862(a)(1)(A) of the Act, the QIC reconsideration will consist of a panel of physicians and other health professionals. When the panel reviews services or items rendered by a physician or ordered by a physician, the panel will consist of at least one physician. The QIC for all Part B durable medical equipment (DME) appeals is RiverTrust Solutions, Inc. Reconsiderations should be filed to the QIC on the Reconsideration Request Form provided at the end of this chapter. Reconsideration requests should be mailed to the following address: RiverTrust Solutions, Inc. P.O. Box 180208 Chattanooga, Tennessee 37401-7208 The date of filing, for requests submitted in writing, is defined as the date received by the QIC in their corporate mailroom. If the party has filed the request in person with the QIC, the filing date is the date of filing at such office, as evidenced by the receiving office’s date stamp on the request. If the party has mailed the request for reconsideration to CMS, Social Security Administration, Railroad Retirement Board office or another government agency in good faith within the time limit, and the request did not reach the appropriate QIC until after the time frame to file a request expired, the QIC considers good cause for late filing. (See Section 240, Chapter 29 of the CMS Internet-Only Manual [IOM] Publication 100-04, Medicare Claims Processing Manual for additional information relating to “good cause.”) Likewise, if the request is filed with CMS, Social Security Administration, Railroad Retirement Board office or another government agency in person, the QIC considers good cause for late filing. Note: Any additional evidence should be submitted with the request for reconsideration and prior to the reconsideration decision being issued. If all evidence is not submitted prior to the issuance of the reconsideration decision, the supplier will not be able to submit any new evidence to the administrative law judge for further appeal unless they can demonstrate good cause for withholding the evidence from the QIC. The QIC may extend the period for filing if it finds the appellant had good cause for not requesting the reconsideration timely. (See Section 240, Chapter 29 of the CMS IOM Publication 100-04, Medicare Claims Processing Manual for additional information relating to “good cause.”) In order for good cause to 5 Jurisdiction B DME MAC Supplier Manual Chapter 19: Reopenings and Appeals [MARCH 2008] be considered, the appeal request must be in writing. If the QIC finds that the appellant did not have good cause for not requesting reconsideration on time, it may, at its discretion, consider reopening. Note: There is no monetary threshold to be met when filing a reconsideration request to the QIC. Administrative Law Judge Hearing The third level of appeal is an administrative law judge (ALJ) hearing. A hearing before an ALJ of the Social Security Administration may be requested if the appellant is not satisfied with the QIC determination. The ALJ hearing must be requested in writing within 60 days from the date of the QIC’s decision. The request must specifically state that an ALJ hearing is desired and the request must be signed. Suppliers should submit ALJ hearing requests to the following address: Administrative Law Judge Office of Medicare Hearing and Appeals – BP Tower 200 Public Square, Suite 1300 Cleveland, Ohio 44114 Note: Prior to January 1st, 2008, there must be at least $110 in controversy. On or after January 1st, 2008, there must be at least $120 in controversy. Departmental Appeals Board Review If an appellant is dissatisfied with the ALJ decision, they may contact CMS directly for an appeals council review. The appeals council review must be requested within 60 days of the date of the ALJ decision. Federal Court Review If an appellant is still dissatisfied with the decision and the amount in controversy exceeds $1130 prior to January 1st, 2008, or on or after January 1st, 2008 the amount in controversy exceeds $1180, they may request a hearing before the federal court. Time Limit for Filing The time limits for filing appeals vary according to the type of appeal and are noted in Table 1. The time limits for filing a request for redetermination may be extended in certain situations if good cause for late filing is shown. Some conditions that establish good cause include: 1) Incorrect or incomplete information about the subject claim and/or appeal furnished by official sources (CMS, the DME MAC or the Social Security Administration) to the individual; and, 2) Unavoidable circumstances that prevented the individual from timely filing a request for redetermination. Unavoidable circumstances encompass situations that are beyond the individual’s control, such as major floods, fires, tornados and other natural catastrophes. Note: Failure of a billing company or other consultant (that the provider, physician or other supplier has retained) to submit appeals or other information timely does not constitute grounds for finding good cause for the late filing. 6 Jurisdiction B DME MAC Supplier Manual Chapter 19: Reopenings and Appeals [MARCH 2008] Appointment of Representative A person/supplier/physician who files an appeal request on behalf of a beneficiary is not, by virtue of filing the appeal, a representative. The Medicare beneficiary may appoint any individual, including an attorney, to act as his/her representative in dealings with Medicare contractors. Although some parties may pursue a claim or an appeal on their own, others will rely upon the assistance and expertise of others. A representative may be appointed at any point in the appeals process. A representative may help the beneficiary during the processing of a claim or claims, and/or any subsequent appeal. (See the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 29, Section 270.1.10 for information on disclosing information to third parties.) The appointment of a representative is valid for one year from the date signed by both the party and the appointed representative. To act as the beneficiary’s representative, a person/supplier/physician must submit a properly executed appointment of representative. The following information must be included on an appointment of representative form or written statement: The name, address and phone number of the individual. The individual’s Medicare number when the party making the appointment is the beneficiary. A specific individual must be named as the representative. An organization or entity may not be named as the representative, but rather a specific member of that organization or entity must be named. The representative must sign and date the form and list his/her name, address and phone number. A statement that he/she accepts the appointment needs to be included. A statement that the party authorizes the representative to act on her or his behalf for the claims at issue and a statement authorizing disclosure of individually identifying information to the representative. The signature of the party making the appointment and the date signed. Note: A representative must sign the appointment within 30 calendar days of the party’s signature. The appointment of representative is valid for one year from either: (1) The date signed by the party making the appointment, or (2) The date the appointment is accepted by the representative— whichever is later. The appointment remains valid for any subsequent levels of appeal on the claim/service in question unless the beneficiary specifically withdraws the representative’s authority. However, if during an appeal the appointment of representative expires, a new form is necessary. A suggested Appointment of Representative Form is located at the end of this chapter. Documentation in the Appeals Process The following clarifications are designed to assist suppliers who wish to appeal original claim denials through the appeals process. Original claim denials are often upheld at the redetermination or reconsideration level of appeal due to the lack of documentation supporting the medical necessity of services rendered. 7 Jurisdiction B DME MAC Supplier Manual Chapter 19: Reopenings and Appeals [MARCH 2008] Before requesting a redetermination or reconsideration, consult the Jurisdiction B DME MAC Supplier Manual, supplier bulletins and all applicable medical policy and documentation guidelines for each piece of equipment/supply being appealed. Failure to include all appropriate documentation with the appeal may result in an unfavorable decision. The appellant has the responsibility to provide information and/or documentation for supplier submitted appeals. Decisions at these levels are based exclusively on the information and/or documentation submitted with the case. The examples below describe common denial situations presented through the appeals process: 1) Medical necessity of DMEPOS items. Medical necessity is established by copies of medical records that address the condition of the patient and how the item in question fits into the treatment plan of the patient. Depending on the item in question, the documentation would include, for example, some of the following information: The diagnosis relating to the limitations and or relating to the need for the equipment/supply Complicating medical conditions Functional abilities (e.g., ability to ambulate or transfer; the distance that the patient can walk independently and/or with the assistance of a walker or other ambulatory aid; abilities of the upper and lower extremities [including tone, range of motion limitations, etc.]) Amount of time in bed, chair or wheelchair Frequency and type of activities outside the home, Functional limitation, Rehabilitation potential (including recent prior functional level) Duration of the condition, Description of and response to prior treatment experience with other equipment prognosis, Physical examination findings, test results, etc. CMN if required Note: If a patient can bear weight to transfer from a bed to a chair or wheelchair, the patient is considered nonambulatory. 2) Individual consideration pricing determinations. If it is an item, the brand name and model name/number should be given and copies of the invoice and/or catalogue with prices should be included. If it is a custom made item, include a detailed description and/or photograph. If it is a service (e.g., repair, custom item), list the labor time and the major materials used and their cost. In addition to the documentation types described above, copies of the doctor’s orders or narrative explanations by the supplier/physician may assist in clarifying the medical necessity of items/services provided. Handwritten documentation must be legible to be effective in the appeal process. 3) Same or similar equipment. It is the responsibility of the beneficiary and supplier to coordinate with all the involved parties to ensure that equipment is only provided when it is 8 Jurisdiction B DME MAC Supplier Manual Chapter 19: Reopenings and Appeals [MARCH 2008] medically necessary and to determine the equipment provided the patient is not a duplication of previously obtained equipment. Note: The following guidelines pertain to claim submission to the Jurisdiction B DME MAC. If a supplier is billing for a new capped rental period, the code must have modifier KH and an initial CMN must accompany the claim if a CMN is required for the code. When the DME MAC receives a claim for a capped rental code that has been previously approved and there has been any interruption of billing to the DME MAC, the presumption is that there has been no interruption in medical necessity for the item—unless it is clearly documented. Therefore, if there is a 60-plus day interruption of billing for a capped rental code (whether or not that code requires a CMN), and the supplier thinks that starting a new capped rental period is justifiable, narrative documentation must accompany the claim. The documentation must include, but is not limited to: 1) a pick up slip from other supplier(s); 2) a delivery slip from current supplier; (Note: If pick up and delivery slips are not submitted, Medicare will continue to allow payment to the other supplier.) 3) a description of the patient’s prior medical condition which necessitated the previous item; 4) a statement explaining when and why the medical necessity for the previous item ended; and 5) a statement explaining the patient’s new or changed medical condition and when the new need began. (This information must be entered in the NTE [Note] segment of an electronic claim or attached to a paper claim. Though suppliers should always try to determine whether a beneficiary has had the same or related equipment before, there are situations in which a supplier may submit an initial claim for a capped rental item not knowing that another supplier has previously been approved for the same or related code. Since in this situation additional narrative documentation justifying the start of a new capped rental period will not have been sent with the claim, the DME MAC will presume that there has been no substantial change in the medical necessity for the item. If coverage criteria for the item are met, the code will be approved, but the modifier will be changed from KH to KI or KJ as appropriate to indicate that it is being processed and paid as a continuation of a previous capped rental situation. If the new supplier disagrees with this determination, they can obtain the information described above and submit the claim as an appeal. 9 Jurisdiction B DME MAC Request for Redetermination Form Supplier Name: _________________________________________________ Supplier Number: ________________ Supplier Address: __________________________________________________________________________________ Supplier Telephone Number: ________________________________________________________________________ Name of Person Requesting the Redetermination: ______________________________________________________ Type of Claim: (Check one) ___ Diabetic Supplies ___ Eyewear/Lenses/ Frames ___ Ostomy/Urological ___ Oxygen/Nebulizer/ CPAP ___ Suction/Trach Supplies ___ Surgical Dressings ___ Hospital Beds/ Support Surfaces ___ Parenteral/Enteral ___ Infusion Drugs/ Pumps ___ Prosthetics/ Orthotics/Splints ___ Wheelchairs/Seat Lifts/ ___ Other Supplies/ POV Equipment Claim Information Beneficiary Medicare # Claim Control # Service Date(s) Date of Initial Determination Reason for Request Please be specific. Describe the service and the action you want Medicare to take. Attach any documentation to support your request: ________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Supplier Signature: ______________________________________________ Date: ____________________________ Mail Completed Form To: Jurisdiction B DME MAC Redetermination P.O. Box 6036 Indianapolis, Indiana 46206-6036 National Government Services, Inc. Page: 1 of 1 Jurisdiction B DME MAC Reconsideration Request Form Redetermination/Appeals Number: Instructions If you wish to appeal the redetermination decision, please complete the information below and mail this form (or a copy of this form) along with a copy of the redetermination decision to the following address: RiverTrust Solutions, Inc. P.O. Box 180208 Chattanooga, Tennessee 37401‐7208 Claim Information 1. Name of beneficiary: _____________________________________________________________________________ 2. Medicare Number:_______________________________________________________________________________ 3. Provider Name: _________________________________________________________________________________ 4. Person appealing the decision: Beneficiary Provider/Supplier Representative of Service 5. Address of the person appealing: __________________________________________________________________ _______________________________________________________________________________________________ 6. Item or service you wish to appeal:_________________________________________________________________ _______________________________________________________________________________________________ 7. Date of service: From: ___________________ To: _____________________ 8. Does this appeal involve an overpayment? Yes No 9. Why do you disagree, or, what are your reasons for your appeal? (Attach additional pages if necessary.) _______________________________________________________________________________________________ _______________________________________________________________________________________________ 10. You may also include any supporting material to assist your appeal. Examples of supporting materials include: Medical records Office records/progress notes Copy of the claim Treatment plan Certificate of Medical Necessity 11. Printed name of person appealing: _________________________________________________________________ 12. Signature of person appealing: ____________________________________________________________________ Contractor Number: _______________________ (This is optional for contractors with only one location for Qualified Independent Contractors to request case files.) National Government Services, Inc. Page: 1 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB no. 09380950 APPOINTMENT OF REPRESENTATIVE NAME OF BENEFICIARY MEDICARE NUMBER SECTION I: APPOINTMENT OF REPRESENTATIVE To be completed by the beneficiary: I appoint this individual: ___________________________________ to act as my representative in connection with my claim or asserted right under Title XVIII of the Social Security Act (the “Act”) and related provisions of Title XI of the Act. I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my appeal, wholly in my stead. I understand that personal medical information related to my appeal may be disclosed to the representative indicated below. SIGNATURE OF BENEFICIARY DATE STREET ADDRESS PHONE NUMBER (AREA CODE) CITY STATE ZIP SECTION II: ACCEPTANCE OF APPOINTMENT To be completed by the representative: I, ________________________________, hereby accept the above appointment. I certify that I have not been disqualified, suspended, or prohibited from practice before the Department of Health and Human Services; that I am not, as a current or former employee of the United States, disqualified from acting as the beneficiary’s representative; and that I recognize that any fee may be subject to review and approval by the Secretary. I am a / an__________________________________________________________________________________________ (PROFESSIONAL STATUS OR RELATIONSHIP TO THE PARTY, E.G. ATTORNEY, RELATIVE, ETC.) SIGNATURE DATE STREET ADDRESS PHONE NUMBER (AREA CODE) CITY STATE ZIP SECTION III: WAIVER OF FEE FOR REPRESENTATION Instructions: This form should be filled out if the representative waives a fee for such representation. (Note that providers or suppliers may not charge a fee for representation and thus, all providers or suppliers that furnished the items or services at issue must complete this section.) I waive my right to charge and collect a fee for representing __________________________________________________ before the Secretary of the Department of Health and Human Services. SIGNATURE DATE SECTION IV: WAIVER OF PAYMENT FOR ITEMS OR SERVICES AT ISSUE Instructions: Providers or suppliers that furnished the items or services at issue must complete this section if the appeal involves a question of liability under section 1879(a)(2) of the Act. (Section 1879(a)(2) generally addresses whether a provider/supplier or beneficiary did not know, and could not reasonably be expected to know, that the items or services at issue would not be covered by Medicare.) I waive my right to collect payment from the beneficiary for furnished items or services at issue involving 1879(a)(2) of the Act. SIGNATURE Form CMS1696 (07/05) EF (07/2205) DATE CHARGING OF FEES FOR REPRESENTING BENEFICIARIES BEFORE THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection with an appeal before the Department of Health and Human Services (DHHS) at the Administrative Law Judge (ALJ) or Medicare Appeals Council (MAC) level is required by law to obtain approval of the fee in accordance with 42 CFR §405.910(f). A claim that has been remanded by a court to the Secretary for further administrative proceedings is considered to be before the Secretary after the remand by the court. The form, “Petition to Obtain Representative Fee” elicits the information required for a fee petition. It should be completed by the representative and filed with DHHS. Where a representative has rendered services in a claim before DHHS, the regulations require that the amount of the fee to be charged, if any, for services performed before the Secretary of DHHS be specified. If any fee is to be charged for such services, a petition for approval of that amount must be submitted. An approval of a fee is not required where the appellant is a provider or supplier or where the fee is for services (1) rendered in an official capacity such as that of legal guardian, committee, or similar courtappointed office and the court has approved the fee in question; (2) in representing the beneficiary before the federal district court of above, or (3) in representing the beneficiary in appeals below the ALJ level. If the representative wishes to waive a fee, he or she may do so. Section III on the front of this form can be used for that purpose. In some instances, as indicated on the form, the fee must be waived for representation. AUTHORIZATION OF FEE The requirement for the approval of fees ensures that representative will receive fair value for the services performed before DHHS on behalf of a claimant while at the same time giving a measure of security to the beneficiaries. In approving a requested fee, the ALJ or MAC considers the nature and type of services performed, the complexity of the case, the level of skill and competence required in rendition of the services, the amount of time spent on the case, the results achieved, the level of administrative review to which the representative carried the appeal and the amount of the fee requested by the representative. CONFLICT OF INTEREST Sections 203, 205 and 207 of Title XVIII of the United States Code make it a criminal offense for certain officers, employees and former officers and employees of the United States to render certain services in matters affecting the Government or to aid or assist in the prosecution of claims against the United States. Individuals with a conflict of interest are excluded from being representatives of beneficiaries before DHHS. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09380950. The time required to prepare and distribute this collection is 15 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the beneficiary. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 212441850. Form CMS1696 (07/05) EF (07/2205) DEPARTMENT OF HEALTH AND HUMAN SERVICES OFFICE OF MEDICARE HEARINGS AND APPEALS REQUEST FOR MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE ❏ Part A Effective July 1, 2005. For use by party to a reconsideration determination issued by a Qualified Independent Contractor (QIC) ❏ Part B (Amount in controversy must be $100 or more.) Send copies of this completed form to: Original — Office of Medicare Hearings and Appeals Field Office specified in the QIC Reconsideration Notice Copy — Appellant Copy — All other parties Failure to send a copy of this completed request to the other parties to the appeal will delay the start date of your appeal. Did you send all required copies? ❏ Yes ❏ No Appellant (The party appealing the reconsideration determination) Beneficiary Provider or Supplier (Leave blank if same as the appellant.) Address (Leave blank if same as the appellant.) Address City State Area Code/Telephone Number Zip Code E-mail Address City State Area Code/Telephone Number Zip Code E-mail Address Document control number assigned by the QIC Health Insurance (Medicare) Claim Number Dates of Service From QIC that made the reconsideration determination To I DISAGREE WITH THE DETERMINATION MADE ON MY APPEAL BECAUSE: ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ You have a right to be represented at the hearing. If you are not represented but would like to be, your Office of Medicare Hearings and Appeals Field Office will give you a list of legal referral and service organizations. (If you are represented and have not already done so, complete form CMS-1696.) Check Only One Statement: ❏ ❏ I wish to have a hearing. I do not wish to have a hearing and I request that a decision be made on the basis of the evidence in my case. (Complete form HHS-723, “Waiver of Right to an ALJ Hearing.”) Check Only One Statement: ❏ I have additional evidence to submit. ❏ I have no additional evidence to submit. If you have additional evidence to submit, please attach the evidence or attach a statement explaining what you intend to submit and when you intend to submit it. If you are a provider, supplier, or beneficiary represented by a provider or supplier, the evidence must be accompanied by a good cause statement explaining why the evidence is being submitted for the first time at the ALJ level. The appellant should complete No. 1 and the representative, if any, should complete No. 2. If a representative is not present to sign, print his or her name in No. 2. Where applicable, check to indicate if appellant will accompany the representative at the hearing. ❏ Yes ❏ No 1. (Appellant’s Signature) Date State Area Code/Telephone Number Date ❏ Attorney ❏ Non-Attorney Address Address City 2. (Representative’s Signature/Name) Zip Code E-mail Address City Area Code/Telephone Number State Zip Code E-mail Address Answer the following questions that apply: A) Does request involve multiple claims? (If yes, a list of all the claims must be attached.) B) Does request involve multiple beneficiaries? (If yes, a list of beneficiaries, their HICNs and the dates of service.) C) Did the beneficiary assign his or her appeal rights to you as the provider/supplier? ❏ Yes ❏ No ❏ Yes ❏ No ❏ Yes ❏ No (If yes, you must complete and attach form CMS-20031. Failure to do so will prevent approval of the assignment.) Must be completed by the provider/supplier if representing the beneficiary: I waive my rights to charge and collect a fee for representing ________________________________________________before the Office of (Beneficiary name) Medicare Hearings and Appeals. Signature of provider/supplier representing beneficiary CMS-20034 A/B U3 (08/05) EF 08/2005 ATTACH A COPY OF THE RECONSIDERATION DETERMINATION (IF AVAILABLE) TO THIS COPY. Date Must be completed by the provider/supplier if representing the beneficiary, they furnished the item(s) or services(s) at issue, and the appeal involves a question of liability under section 1879(a)(2) of the Social Security Act: I waive my right to collect payment from the beneficiary for the furnished items or services at issue involving 1879(a)(2) of the Social Security Act. Signature of provider/supplier representing beneficiary Date TO BE COMPLETED BY THE OFFICE OF MEDICARE HEARINGS AND APPEALS Is this request filed timely? ❏ Yes ❏ No If no, attach appellant’s explanation for delay. If there is no explanation, send a Notice of Late Filing of Request for ALJ Hearing to the appellant and representative, if applicable, to request such an explanation. Request received on Field Office Employee Assigned on Assigned by Assigned to Special response case? ❏ Yes ❏ No If yes, explain why and state the targeted adjudication deadline. _______________________________________________________________________________________________________________ ___________________________________________________________________________________ Interpreter/translator needed (including sign language) ❏ Yes ❏ No If yes, type needed: _______________________________________________________________________________________________________________ ___________________________________________________________________________________ If appellant not represented, has a list of legal referral and service organizations been provided. ❏ Yes ❏ No PRIVACY ACT STATEMENT The legal authority for the collection of information on this form is authorized by the Social Security Act (section 1155 of Title XI and sections 1852(g)(5), 1860D-4(h)(1), 1869(b)(1), and 1876 of Title XVIII). The information provided will be used to further document your appeal. Submission of the information requested on this form is voluntary, but failure to provide all or any part of the requested information may affect the determination of your appeal. Information you furnish on this form may be disclosed by the Office of Medicare Hearings and Appeals to another person or governmental agency only with respect to the Medicare Program and to comply with Federal laws requiring the disclosure of information or the exchange of information between the Department of Health and Human Services and other agencies. CMS-20034 A/B U3 (08/05) EF 08/2005 Jurisdiction B DME MAC Supplier Manual Chapter 20: Overpayments [MARCH 2008] 20 Overpayments DME MAC INITIATED DEMAND LETTERS When it has been determined that a supplier has been overpaid, a refund request will be sent to the supplier. An initial demand letter (i.e., overpayment letter) is issued and includes: the the the the the patient name; patient’s Health Insurance Claim number (HICN); Claim Control Number (CCN); Document Control Number (DCN); and reason for the recovery action. The demand letter will identify the services that triggered the overpayment process. Two items in the demand letter warrant immediate attention; one is the 11-digit DCN. The supplier must reference the DCN in any communication with the DME MAC. The DCN is used to track the refund. A self-addressed envelope is enclosed with this demand letter that contains the code of the Medicare person handling the request. Use this envelope so that proper action will be taken. The supplier has 30 days from the date of the demand letter to refund the DME MAC. If the DME MAC has not received the refund within this 30-day period, interest begins to be added to the refund amount. A second demand letter is sent between the 30th and 45th day. If full payment is not received by the 40th day from the date of the initial demand letter, the offset process (deducting from the supplier’s Medicare check) is started. Future payments will be offset until the overpayment is recouped. If the offset procedure has begun and payment is subsequently received, interest will be deducted, the amount that had already been applied by offset will be deducted and the balance returned to the supplier. Note: When the offset is less than $10, the offset is begun on the 40th day. In this case, a second demand letter is not sent. THE OFFSET PROCESS If a refund is not received before the deadline date, an offset begins. Medicare will reduce any future payments by the amount of the refund. Medicare will also take interest on the overdue amount. The minimum interest charged is accrued every 30 days on the refund amount. The offset will be reported to the supplier on the remittance notice by a Financial Control Number (FCN). No other written notices will be sent. The FCN on the remittance notice will match the DCN on the refund request letter. No other details identifying the offset will be given on the remittance notice. The offset and interest charges will continue until the full refund amount is recouped. Note: The FCN is found in the “Offset Detail” line of the supplier remittance notice. 1 Jurisdiction B DME MAC Supplier Manual Chapter 20: Overpayments [MARCH 2008] IMMEDIATE OFFSET BY FAX The Overpayment and Recovery Unit (ORU) has developed an offset form for suppliers to utilize when an overpayment has been identified and the supplier wishes for the DME MAC to take the money back via an offset versus sending in the overpayment. This form can also be utilized for voluntary refund requests. This form must be completed in its entirety and fax to: 317-913-6164. A copy of this offset form can be found at the end of this chapter, or by accessing the National Government Services Web site at www.adminastar.com/Providers/DMERC/MedicareManuals/files/OffsetRequestForm.pdf. Note: If a supplier has requested an immediate offset but there are no claims for the recoupment within thirty days, interest will be assessed and a second letter will be sent. The collection process will continue until the full amount is collected. APPEALING A REFUND When a refund request is received, the supplier should refund the amount requested and then file an appeal. This will avoid an offset with interest charges. If the overpayment letter is dated on or after January 1, 2006, regardless of the dollar amount, the supplier must submit a redetermination request. The only time the supplier would need to request a reconsideration, which is the second level of the appeals process, is if the overpayment resulted from a redetermination request. If the refund resulted from a redetermination request, a reconsideration must be filed to RiverTrust Solutions, Inc. To contact RiverTrust Solutions, visit their Web site at www.rivertrustsolutions.com. The following address must be used to submit a reconsideration request: RiverTrust Solutions, Inc. P.O. Box 180208 Chattanooga, Tennessee 37401-7208 The overpayment letter will have detailed instructions on how to file for an appeal. SUPPLIER VOLUNTARY REFUNDS All voluntary refunds should be sent to the ORU at National Government Services as soon as discovered. A voluntary refund form has been developed to simplify the return of refunds, and is located at the end of this chapter. Even though the refund check involves more than one Medicare patient, a separate form should be completed for each patient. The form should be copied and included anytime refunds are made to Medicare. When submitting a voluntary refund, please make the check payable to National Government Services. If a provider does not use the suggested Voluntary Refund Form, the following information must be included: A supplier number A copy of the supplier remittance – If no supplier remittance is available, provide the date(s) of service(s) and include the procedure code(s) 2 Jurisdiction B DME MAC Supplier Manual Chapter 20: Overpayments [MARCH 2008] Reason for the refund (be specific as to the reason) Patient’s name and HIC number, i.e., Medicare identification number Note: Please send all Medicare Secondary Payer (MSP) refund checks and refund correspondence to the following address and utilize the appropriate MSP refund form located in the Medicare Secondary Payer chapter of this manual. Medicare MSP DME MAC Lockbox #660065 Indianapolis, Indiana 46266-0065 (Refund checks and refund correspondence) LOST OR MUTILATED CHECKS When a check is lost, a written request for replacement should be sent to the ORU after 90 days has elapsed from the date of issue. The ORU will review bank records and upon identification that the check has not been cashed, they will stop payment and reissue a check. When a check has been damaged in the mail and cannot be cashed, the check should be returned to the ORU for reissue. The ORU address is: ORU—DME MAC—Indiana Lockbox # 660078 Indianapolis, Indiana 46266-0078 To access an overview of the overpayment process, quarterly tips and forms, visit the ORU page on the National Government Services Web site at www.adminastar.com/Providers/DMERC/PCU/PCU.htm. CHANGE OF ADDRESS When a supplier changes their address, the National Supplier Clearinghouse (NSC) must be notified. The NSC may be reached at 866-238-9652, or visit their Web site at www.PalmettoGBA.com/NSC. The NSC will update address files at the DME MAC. If the address file is not updated, cash flow will be interrupted. Medicare checks will not be forwarded by the post office. Returned checks are voided and the money placed in escrow. The DME MAC notifies the NSC of the returned check and the NSC, depending on the situation, will contact the supplier by phone or letter. If the supplier does not respond to the NSC within 30 days, the supplier’s NSC number is inactivated. No payments will be issued until the NSC updates the DME MAC records. When the supplier contacts the NSC, the suspension will be lifted and the supplier must contact Provider Assistance for payment to be reissued along with the remittance notices. 3 Overpayment Recovery Unit Jurisdiction B DME MAC Voluntary Refund Form To Be Completed By Medicare Contractor Date: ___________________________________________ Contractor Deposit Control #: _____________________________________________ Date of Deposit: _________________________________ Contractor Contact Name: _________________________________________________ Phone #: ________________________________________ Contractor Fax: ___________________________________________________________ Contractor Address: __________________________________________________________________________________________________________ To Be Completed By Provider/Physician/Supplier, Or Other Entity Please complete and forward to your Medicare contractor. This form, or a similar document containing the following information, should accompany every unsolicited/voluntary refund so that receipt of check is properly recorded and applied. Physician/Supplier or Other Entity Name: _____________________________________________________________________________________ Address: ____________________________________________________________________________________________________________________ Provider/Physician/Supplier # or NPI #: ____________________________ Tax ID #: _________________________________________________ Contact Person: __________________________________________________ Phone #: _________________________________________________ Amount of Check $: __________________________ Check #: _________________________ Check Date: ______________________________ Refund Information For each claim, provide the following: Patient Name: ___________________________________________________ HICN: ___________________________________________________ Date of Service: __________________________________________________ Medicare Claim Number: __________________________________ Claim Amount Refunded $: _______________________________________ Reason Code for Claim Adjustment: _______________________________ (Reason codes are listed below. Use one reason per claim.) (Please list all claim numbers involved. Attach separate sheet, if necessary) Note: If specific patient/Health Insurance Claim (HIC)/claim #/claim amount data not available for all claims due to statistical sampling, please indicate methodology and formula used to determine amount and reason for overpayment:____________________________________________ Note: If specific patient/HIC/claim # information is not provided, no appeal rights can be afforded with respect to this refund. Providers/physicians/suppliers, and other entities who are submitting a refund under the Office of the Inspector General’s (OIG’s) Self‐Disclosure Protocol are not afforded appeal rights as stated in the signed agreement presented by the OIG. For Institutional Facilities Only: Cost report year(s): _________________________________ (If multiple cost report years are involved, provide a breakdown by amount and corresponding cost report year.) For OIG Reporting Requirements Do you have a Corporate Integrity Agreement with OIG? Are you a participant in the OIG Self‐Disclosure Protocol? Reason Codes Billing/Clerical: 01 – Corrected date of service 02 – Duplicate 03 – Corrected CPT code 04 – Not our patient(s) 05 – Modifier add/remove 06 – Billed in error Mail Completed Form To Yes Yes No No MSP/Other Payer Involvement: 07 – MSP group health plan insurance 08 – MSP no‐fault insurance 09 – MSP liability insurance 10 – MSP, Workers’ Comp. (including Black Lung) 11 – Veterans Administration Miscellaneous: 12 – Insufficient documentation 13 – Patient enrolled in HMO 14 – Services not rendered 15 – Medical necessity 16 – Other; be specific: ___________ _______________________________ National Government Services, Inc. Jurisdiction B DME MAC P.O. Box 660078 Indianapolis, Indiana 46266‐0078 National Government Services, Inc. Page: 1 of 1 Form #: Overpayment Recovery Unit Jurisdiction B DME MAC Offset Request Form Instructions This form should be used to initiate a request for immediate offset of an overpayment. There are two types of overpayments: (1) Demanded (i.e., Medicare identified), and (2) Voluntary (i.e., provider identified). Please fill out the appropriate section in its entirety and fax the completed form to (317) 913‐6164. Type of Refund Medicare identified—Section I (demand letter has been received) Provider identified—Section II (no letter has been received) I. Complete This Section for Medicare Identified Refunds Date of Request: _______________________________Amount of Overpayment $:____________________________ Claim Control Number: ________________________Accounts Receivable (AR) Number: ____________________ Notes: • All of the above information can be found on the Medicare demand letter. • Please make sure you attach a copy of the first page of the original demand letter. II. Complete This Section for Provider Identified Refunds Date of Service:________________________________Beneficiary HICN:____________________________________ Claim Control Number: ________________________Amount of Overpayment $:____________________________ Specific Reason for Refund: _________________________________________________________________________ Notes: • All of the information in the section above is required to ensure proper processing. • Please make sure you attach a completed copy of the Voluntary Refund Form for each request. This form can be found on the National Government Services Web site at www.NGSMedicare.com. • A demand letter will be generated once this request has been fulfilled. You may disregard that letter. Provider Information (Required) Name: ________________________________________________ Provider #:__________________________________ Address: ______________________________________________ NPI #: ______________________________________ City/State/Zip:______________________________________________________________________________________ Contact Name: ________________________________________ Phone #: ____________________________________ Signature of Requestor: _____________________________________________________________________________ National Government Services, Inc. Page: 1 of 1 Form #: Jurisdiction B DME MAC Supplier Manual Chapter 21: Customer Care [MARCH 2008] 21 Customer Care Suppliers with questions regarding claim filing, status, or general Medicare inquiries may contact the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) either by telephone or in writing. INTERACTIVE VOICE RESPONSE SYSTEM The Jurisdiction B DME MAC Customer Care Department telecommunications system is equipped with an Interactive Voice Response (IVR) system. The IVR system enables the supplier to obtain information by pressing various numbers on their touch-tone telephone. Suppliers can obtain the following information from the IVR unit: Claim status Last three checks issued or checks issued by date Check beneficiary eligibility Claim offset information Voluntary refund status Appeal rights information and appeal status Obtain Certificate of Medical Necessity (CMN) information located in the Common Working File (CWF) Healthcare Common Procedure Coding System (HCPCS) pricing information The Jurisdiction B DME MAC Customer Care IVR system is available from 6:00 a.m.–7:00 p.m. Eastern Time (ET), Monday through Friday, and 7:00 a.m.–3:00 p.m. ET most Saturdays. However, The IVR unit is not available during system upgrades or routine maintenance. The IVR can be accessed toll free at 877-299-7900. An IVR guide is located on the National Government Services Web site at www.adminastar.com/AboutUs/ContactUs/Telephone/IVR/DMERCProvider.html. CUSTOMER CARE CONTACT CENTER The Customer Care Contact Center is available to assist suppliers with questions they may have concerning billing, coverage, benefits, claims, etc., for their Medicare patients. The telephone unit is a resource for those urgent matters which need an immediate response, those easily and quickly answered questions, or for the problems that are too complicated to write. Every attempt is made to service as many suppliers as possible each day. Therefore, the number of inquiries made by phone is limited to three per call so that the telephone lines are not tied up taking lists of questions. Each time a telephone or written inquiry is made to the Jurisdiction B DME MAC Customer Care Contact Center, the supplier, provider, clearinghouse, billing agency, etc., is required to meet the authenticating elements outlined in the Disclosure Desk Reference. This process helps to protect the privacy of Medicare beneficiaries, and ensures that any protected health information (PHI) is disclosed to providers only when appropriate. 1 Jurisdiction B DME MAC Supplier Manual Chapter 21: Customer Care [MARCH 2008] Note: For a complete outline of the authenticating elements, please refer to the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-09, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 6, Sections 80–80.5. The Customer Care Contact Center is available from 8:30 a.m.–5:30 p.m. ET, Monday through Friday. The toll-free number for the contact center is 866-590-6727. The Customer Care Contact Center is closed on the following holidays: New Year’s Day Martin Luther King, Jr. Day Memorial Day Independence Day Labor Day Thanksgiving Day and the day after Thanksgiving, and Christmas Day The Customer Care Contact Center may also be closed on the following legal holidays: Columbus Day and Veteran’s Day. In order to ensure customer care representatives (CCRs) are fully informed on the most recent Medicare regulations and changes, and to better serve the supplier, CMS allows Medicare contractors to close for training purposes for up to eight hours per month. After careful review of the supplier Customer Care call inquiry logs, National Government Services has determined the best time to close for training is Friday mornings from 9:00–11:00 a.m. ET, or 8:00–10:00 a.m. Central Time (CT). Therefore, CCRs will not be available during this time frame each week. However, the IVR unit will remain operational to provide suppliers with information that does not require CCR assistance. National Government Services will advise suppliers via the Web site, Listserv message and IVR unit of any changes to this schedule. Suppliers are encouraged to plan their business needs accordingly. A calendar listing the most current dates of these closures will be posted monthly to the “What’s New” page on the National Government Services Web site, and a Listserv message will be sent advising of these dates. The “What’s New” page of the National Government Services Web site can be found at www.adminastar.com/News/DMERCNews/DMERCNews.cfm. TELEPHONE INQUIRIES As a result of CMS Change Request 3376—and in an effort to continually improve the customer service provided to the supplier community—the Jurisdiction B DME MAC Customer Care Contact Center uses a three-tiered system for answering supplier telephone inquiries. This new system allows questions received from suppliers to be answered as quickly and accurately as possible. Calls are now answered by Level 1 and 2 CCRs and by the provider relations research specialist (PRRS). All telephone inquiries will initially be answered by a Level 1 CCR. The Level 1 CCR can assist the supplier with a wide range of basic questions, primarily: 2 Jurisdiction B DME MAC Supplier Manual Chapter 21: Customer Care [MARCH 2008] inquiries that cannot be answered by the IVR unit; inquiries that do not require substantial research; and inquiries that can easily can be answered during the initial call. Level 1 CCRs will assist callers with the following types of inquiries: CMS-1500 claim form completion IVR unit education (i.e., claim status, beneficiary eligibility, Certificate of Medical Necessity [CMN] information) Basic policy questions (Jurisdiction B DME MAC Supplier Manual, bulletins, reference guides) Basic letter questions (Additional Documentation Request [ADR], appeals, Overpayment and Recovery Unit, Medicare Secondary Payer [MSP]) Web site navigation (www.cms.gov, www.NGSMedicare.com) Provider eligibility Pricing and fee schedules Basic claim research, including: – Return/rejects – Beneficiary eligibility – Duplicate denials – Verifying hospice and home health claims through the CWF – Additional Documentation Request questions – Modifier requirements – Health maintenance organization involvement – MSP involvement – Medical necessity – Procedure code versus modifier – Place of service versus provider – Bundling – Noncovered services – End-stage renal disease research through the CWF – Crossover claims – Ordering duplicate remittance notices – Basic appeals research – Basic fraud and abuse research – Basic financial research (paid, mutilated, stop-pay) – Patient responsibility, and – Electronic medial claim submission Depending on the nature of the issue, calls may be referred to a Level 2 CCR. If the Level 2 CCR is not able to resolve the issue immediately, they have ten business days from the day the inquiry is referred from Level 1 to respond. Level 2 CCRs provide additional experience and expertise, enabling them to answer more complex claim and CMN inquiries and in-depth financial and policy research. 3 Jurisdiction B DME MAC Supplier Manual Chapter 21: Customer Care [MARCH 2008] Level 2 CCRs will assist callers with the following types of inquiries: Call backs from Level 1 inquiries Research complex denials (denials that are missing action codes, denials that have complex medical policy involvement, denials that have unclear audits/edits) Financial issues including research offsets, research returned checks, withholdings, research refund requests (locating the Health Insurance Claim number [HICN] and beneficiary name, locating the date of service involved, explain why a refund is being requested), etc. Complex CMN issues Complex payments and/or denials Policy information After the resources available in Level 1 and Level 2 have been exhausted, callers will be referred to Level 3 of the process, which is the PRRS. The PRRS has 45 business days from the day the inquiry is referred from Level 2 to respond, and will handle issues that require additional time and a higher degree of expertise and/or research. Some of the inquiries that a PRRS will assist callers with include: Complex policy research Jurisdiction B DME MAC supplier e-mails and questions sent via the Web site Web site navigation Listserv article clarification (i.e., National Government Services, Medicare Learning Network [MLN] Matters articles, CMS and DME MAC specific) WRITTEN INQUIRIES When submitting an inquiry in writing, please be sure to include the following information: 1) 2) 3) 4) 5) 6) 7) Beneficiary’s name Medicare HICN Service date(s) Service/supply rendered Charges for the supply/service Outline of the problem or questions (be specific) Copy of the original remittance, if applicable Written inquires should be mailed to the following address: National Government Services, Inc. Jurisdiction B DME MAC Correspondence P.O. Box 6036 Indianapolis, Indiana 46206-6036 Note: Please see the Appeals chapter for Medicare Redetermination requests. 4 Jurisdiction B DME MAC Supplier Manual Chapter 22: Resources [MARCH 2008] 22 Resources JURISDICTION B DME MAC CONTACT INFORMATION Administrative Law Judge Office of Medicare Hearing and Appeals–BP Tower 200 Public Square, Suite 1300 Cleveland, Ohio 44114 Medicare Secondary Payer (refund checks and refund correspondence) Medicare MSP DME MAC Lockbox #660065 Indianapolis, Indiana 46266-0065 Beneficiary Help Line 1-800-MEDICARE (1-800-633-4227) Medicare Secondary Payer (correspondence only) P.O. Box 6036 Indianapolis, Indiana 46206-6036 TDD Line for Hearing Impaired: 317-841-4677 Electronic Data Interchange 877- 273-4334 8:00 a.m.–4:00 p.m. Eastern Standard Time (ET) M−F 8:00 a.m.–6:00 p.m. ET for password reset calls only Advanced Determination of Medicare Coverage National Government Services, Inc. Attn: Medical Review—ADMC P.O. Box 6036 Indianapolis, Indiana 46206-6036 E-Commerce: Fax: 317-595-4759 Helpdesk: 804-746-7082 (Lisa Hare) 414-774-4556 (Pat Graham) Written Correspondence P.O. Box 6036 Indianapolis, Indiana 46206-6036 Reconsiderations (For reconsiderations on or after December 1, 2006) RiverTrust Solutions, Inc. P.O. Box 180208 Chattanooga, Tennessee 37401-7208 For overnight deliveries: 801 Pine Street Chattanooga, Tennessee 37402 Redeterminations P.O. Box 6036 Indianapolis, Indiana 46206-6036 Fraud and Abuse TriCenturion P.O. Box 100282 Columbia, South Carolina 29202-3282 803-264-7700 Refunds Overpayment Recovery Unit ORU—DME MAC—Indiana Lockbox #660078 Indianapolis, Indiana 46266-0078 National Government Services, Inc. Web Site www.NGSMedicare.com 1 Jurisdiction B DME MAC Supplier Manual Chapter 22: Resources [MARCH 2008] Freedom of Information (FOI) P.O. Box 50454 Indianapolis, Indiana 46250-0454 Customer Care Contact Center 866-590-6727 8:30 a.m.–5:30 p.m. ET Telephone Reopenings 317-841-1307 8:00 a.m.–4:00 p.m. ET Interactive Voice Response (IVR) Unit 877-299-7900 6:00 a.m.–7:00 p.m. ET Coordination of Benefits Medicare—Coordination of Benefits P.O. Box 5041 New York, New York 10274-5041 1-800-999-1118 Claim Filing Addresses: All DMEPOS Claims P.O. Box 7027 Indianapolis, Indiana 46207-7027 DMEPOS Additional Documentation Requests (ADRs) P.O. Box 7027 Indianapolis, Indiana 46207-7027 Additional Resources: National Supplier Clearinghouse (NSC) Palmetto GBA AG-495 P.O. Box 100142 Columbia, South Carolina 29202-3142 Jurisdiction A National Heritage Insurance Company 75 Sgt. William Terry Drive Hingham, Massachusetts 02043 866-419-9458 8:00 a.m.–4:00 p.m. ET, M–F www.medicarenhic.com 866-238-9652 8:00 a.m.–8:00 p.m. ET www.PalmettoGBA.com/NSC. Jurisdiction C CIGNA Government Services P.O. Box 20010 Nashville, Tennessee 37202 Jurisdiction D Noridian Administrative Services 901 40th Street South; Suite 1 Fargo, North Dakota 58103 866-270-4909 9:00 a.m.–5:00 p.m. ET www.cignagovernmentservices.com 866-243-7272 8:00 a.m.–5:30 p.m. Central Standard Time (CT) www.noridianmedicare.com Federal Black Lung Claims CSC Correspondence Unit P.O. Box 740 Lanham, Maryland 20706 Office of Investigation Department of Health and Human Services Office of Inspector General 105 West Adams Chicago, Illinois 60603 U.S. Government Printing Office Superintendent of Documents Rail Road Retirement Board 800-808-0772 (choose option 5 for local information) To order claim forms call: 202-512-1800 8:00 a.m.–4:30 p.m. ET 2 Jurisdiction B DME MAC Supplier Manual Chapter 22: Resources [MARCH 2008] JURISDICTION B DME MAC FORMS INDEX Supplier Manual Reference Online Link CMS-R-131-6 Advance Beneficiary Notice Chapter 9 www.cms.hhs.gov/BNI/Downloads/CMSR131G.pdf Advanced Determination of Medicare Coverage Request Form Chapter 8 http://www.adminastar.com/Providers/DMERC/Forms/files/ADMCForm.pdf Certificate of Medical Necessity Forms Chapter 6 www.adminastar.com/Providers/DMERC/Forms/cmns.htm CMS-1500 Claim Form Chapter 11 www.cms.hhs.gov/cmsforms/downloads/CMS1500805.pdf CMS-382 ESRD Beneficiary Selection Form Chapter 14 www.adminastar.com/Providers/DMERC/MedicareManuals/files/CMS382ESRDBeneSelectionForm.pdf Order Form for Region B/ Jurisdiction B Supplier Publications Not Applicable www.adminastar.com/Providers/DMERC/MedicareManuals/files/september2006OrderForm.pdf Medicare Redetermination Request Form Chapter 19 www.adminastar.com/Providers/DMERC/Forms/files/Redetermination%20Form.pdf Medicare Reconsideration Request Form Chapter 19 www.adminastar.com/Providers/DMERC/Forms/files/Reconsideration%20Form.pdf CMS-20034 Request for Medicare Hearing by An Administrative Law Judge Chapter 19 www.adminastar.com/Providers/DMERC/MedicareManuals/files/ALJRequestForm.pdf CMS-1696 Appointment of Representative Sample Form Chapter 19 www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf Form Name 3 Jurisdiction B DME MAC Supplier Manual Chapter 22: Resources [MARCH 2008] Supplier Manual Reference Online Link ORU Voluntary Refund Form Chapter 20 www.adminastar.com/Providers/DMERC/Forms/files/PCU_Voluntary%20Refund%20Form.pdf ORU Offset Request Form Chapter 20 www.adminastar.com/Providers/DMERC/Forms/files/PCU_Offset%20Request%20Form.pdf Medicare Secondary Payer Voluntary Refund Form Chapter 4 www.adminastar.com/Providers/DMERC/MedicareManuals/files/MSPvoluntaryrefundform.pdf Medicare Secondary Payer Offset Request Form Chapter 4 www.adminastar.com/Providers/DMERC/MedicareManuals/files/MSPOffsetbyfaxform.pdf CMS-855S Medicare Enrollment Application Form Not Applicable www.cms.hhs.gov/cmsforms/downloads/cms855s.pdf CMS-533 Electronic Funds Transfer Form Not Applicable www.cms.hhs.gov/cmsforms/downloads/CMS588.pdf Documentation Inventory Form Not Applicable www.adminastar.com/Providers/DMERC/Forms/files/JurisdictionBCMSDIF.pdf Form Name 4 Jurisdiction B DME MAC Supplier Manual Chapter 22: Resources [MARCH 2008] ACRONYMS AARP ADMC ADP ADR ALJ AMA ANSI AOB ASCA ASP AWP BBA BBRA BIPA CCN CERT CMN CMR CMS CMS-1500 CMS-1696 CMS-20034 CMS-382 CMS-5011B CMS-533 CMS-855S CMS-R-131-6 CO COB CPT CPT-4 CFR CSI CWF DAB DCN DIF DME DME MAC DMEPOS DMERC DO DOJ DOS American Association of Retired Persons Advanced Determination of Medicare Coverage Automated data processing Additional documentation request Administrative law judge American Medical Association American National Standards Institute Assignment of benefits Administrative Simplification Compliance Act Average sales price Average wholesale price Balanced Budget Act of 1997 Balanced Budget Refinement Act of 1999 Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 Claim Control Number Comprehensive Error Rate Testing Certificate of Medical Necessity Comprehensive medical review Centers for Medicare & Medicaid Services Health insurance claim form Appointment of Representative Form Request for Part B Medicare Hearing By an Administrative Law Judge ESRD Beneficiary Selection Form Request for Part B Medicare Hearing by an Administrative Law Judge Electronic Funds Transfer form Medicare Supplier Number Application form Advance Beneficiary Notice form Contracting officer Coordination of benefits Claims processing timeliness Current procedural terminology Code of Federal Regulations Claim Status Inquiry Common Working File Departmental appeals board Document Control Number DME Information Form Durable medical equipment Durable medical equipment Medicare administrative contractor durable medical equipment, prosthetics, orthotics, and supplies Durable medical equipment regional carrier Doctor of osteopathy Department of Justice Date of service 5 Jurisdiction B DME MAC Supplier Manual Chapter 22: Resources [MARCH 2008] DPM DRA EDI EFT EGHP EIN ERA ESRD FBI FCN FI FOI HCPCS HHA HHS HICN HIPAA HME HMO ICD-9-CM ICN IIC IOM IRP IRS IV IVR LCD LCL LGHP MD MHO MMA MREP MSN MSP NCD NCPDP NF NOC NON-PAR NPI NSC NSF OAS OBRA OD Doctor of podiatric medicine Deficit Reduction Act of 2005 Electronic data interchange Electronic funds transfer Employer group health plans Employer identification number Electronic remittance advice End-stage renal disease Federal Bureau of Investigations Financial Control Number Fiscal intermediary Freedom of Information Healthcare Common Procedure Coding System Home health agency Health and Human Services Health Insurance Claim Number Health Insurance Portability and Accountability Act of 1996 Home medical equipment Health maintenance organization International Classification of Diseases, Clinical Modification, 9th Revision Internal Claim Number Inflation-indexed charges CMS Internet-Only Manual System Inexpensive or other routinely purchased DME Internal Revenue Service Intravenous Interactive Voice Response system Local coverage determination Lowest charge level Large group health plan Doctor of medicine Medicare hearing officer Medicare Modernization Act of 2003 Medicare Remit Easy Print Software Medicare Summary Notice Medicare Secondary Payer National coverage determination National Council for Prescription Drug Programs Nursing facility Not otherwise classified Nonparticipating provider National provider identifier National Supplier Clearinghouse National standard format Office of Audit Service of the Department of Health and Human Services Omnibus Budget Reconciliation Act Optometrist (doctor of optometry) 6 Jurisdiction B DME MAC Supplier Manual Chapter 22: Resources [MARCH 2008] OI OIG OIFO ORU OTR PAR PEN PHI PIN PMD POTR POV QIC RA RHHI RICO RO SADMERC SNF SPR SSA SSN TENS UPIN VA WAC WC ZPIC Office of Investigations Office of the Inspector General Office of Investigations Field Office (OIG) Overpayment Recovery Unit On-the-record hearing Participating provider Parenteral and enteral nutrition Protected health information Provider Identification Number Power mobility device Preliminary on-the-record hearing Power operated vehicle Qualified independent contractor Remittance advice Regional home health intermediary Racketeering Influenced Corrupt Organization Regional office (CMS) Statistical Analysis DMERC Skilled nursing facility Standard paper remittance Social Security Administration Social Security Number Transcutaneous electrical nerve stimulator Unique Provider Identification Number Veterans Administration Wholesale acquisition cost Workers’ Compensation Zone program integrity contractor 7