DAC QUESTIONS for
CIGNA Meeting in Orlando, FL
October 5, 2000
HME Questions
1. What would be the reason for one invoice to deny on two different days with two different denial
reasons? For example, if a claim was inadvertently submitted twice, why wouldn’t both of those
claims be denied with the same denial reason? (Two examples are attached below 5a and 5b.)
1. The Answer: Since we did not have the HICN we could not look these over in our system.
2. If a claim is sent in to review due to the equipment being downcoded inappropriately (i.e., patient
qualified for E0260 but E0255 was paid) will the CMN be updated permanently in the CWF so
future dates of service will pay correctly on the original submission without having to go through
the review process?
2. The Answer: The reviewer will update the CMN according to the decision made in the
review. If the CMN is updated, it will also be updated at CWF and then subsequent
claims will be processed against the updated CMN .
3. Are CMNs in the CWF accessible to all four DMERCs? For example, if we bill Region B for a
patient whose permanent address is in Florida and we receive a 109 denial then resubmit the
claim to Region C, do we need to resubmit the CMN or should Region C have access to the
CMN?
3. The Answer: CMNs are accessible to all four DMERCs at CWF. However, each
DMERC may handle this process in a different way. In Region D you would need to
document on the claim that this beneficiary has moved to Region D and already had a
CMN file with the other Region. If sending electronically please indicate this in your
HA0 record.
4. Are gloves, sterile or non-sterile, (A4927) covered items? If so, what are the coverage
guidelines?
4. The Answer: Yes, only for patients who qualify under ESRD under the Home Dialysis and
Supplies in the Supplier Manual Chapter IX starting with page 23.
5. A4602 (gauze, non-impregnated)**** We are assuming you meant A6402.
6. Q1. Is this a covered item for trach patients if they are not receiving trach care kits (A4625 or
A4629) in the same month?
Q1. The Answer: The correct code for sterile non-impregenated gauze 16 sq. in. or less is
A6402. These dressings are a covered item for trach patients if they are not receiving
trach care kits AND they have a wound meeting one of these criteria:
- it is caused by, or treated by, a surgical procedure, or
- it is medically necessary to debride the wound.
When the criteria is met, the gauze pads must be billed with the appropriate
modifier X1 - X9 indicating the dressing is used on a surgical wound and the
number of wounds for which the dressings billed are used.
Once the stoma has healed, it is no longer a qualifying wound.
Gauze pads used to clean or debride the stoma area or wound and not left on the
wound are not covered and must not be billed with modifier X1 - X9. In this case
there is no benefit under which to cover the gauze pads; they are a noncovered
disposable supply.
Q2. When billing this item for trach patients, does this item require the X1-X9 modifier?
Q2. The Answer: Refer to Q1.
Q3. What documentation should be entered into the HAO record to avoid the initial denial?
Q3. The Answer: There should be none needed if the claim is otherwise billed correctly.
7. A4320 (Irrigation tray w/bulb or piston syringe) - The medical policy states that this item is
covered when used for "non-routine" purposes. Can you please define "non-routine?" The
medical policy does not state any diagnoses or circumstances that would be considered "nonroutine."
Are there specific diagnoses or is there documentation that should be entered in the
HAO record to prevent the initial denial?
7. The Answer: As stated in the Urological Supplies policy (SM IX-37.2), irrigation trays
(A4320) are covered for medically necessary non-routine intermittent irrigation of a
indwelling catheter on an as-needed basis in the presence of acute obstruction of the
catheter. [Emphasis added.] This policy further states, "Routine irrigations are defined
as those performed at predetermined intervals." An example of a routine irritation is
"irrigate catheter once a day…" Irrigation trays for intermittent catheter irrigation are
only covered when used in conjunction with covered indwelling catheters. This must be
documented on the claim by appending modifier ZX to the code for the irrigation tray.
Other documentation needs would be determined based on the reason for the initial
denial, which is not stated in the question.
8. A4628 (Oropharyngeal suction catheters) - The medical policy does not indicate any utilization
guidelines. Are there utilization requirements? What documentation should be included in the
HAO record to avoid the initial denial? This is a follow up question to the August 14, 2000
response. The response gave utilization for A4624, suction catheters, not A4628.
8. The Answer: Code A4628 is used when billing for the "Yankauer"-type rigid
oropharyngeal suction device. We have not established utilization guidelines for this
code. Medical review for utilization of this type of suction device would take into
consideration that it can be cleaned and reused and that sterility is not required for oral
and oropharyngeal suctioning. They should be replaced only as needed. They are
covered only when used in conjunction with a covered suction pump. The need for and
type of accompanying documentation is contingent on the type of denial anticipated. If
denial for excessive supply utilization is anticipated, document must be patient specific
and should describe what aspect of the patient's condition necessitates the quantity billed
and over what period of time that quantity is intended to be used (e.g., one week, one
month, etc). Information submitted by the supplier must be corroborated by
documentation in the patient's medical records that Medicare coverage criteria are met
and is available to the DMERC upon request. The patient's medical records include the
physician's office records, hospital records, nursing home records, home health agency
records or records from other healthcare professionals.
9. When a patient is receiving supply items that are over the utilization guidelines set by the
DMERC what additional documentation would be considered justification for the medical
necessity of the overutilization (i.e. letter from physician, progress notes, etc.)?
9. The Answer: In some cases an applicable RMRP Documentation section indicates
specific documentation requirements. For example, the Nebulizer policy states "each
claim must be accompanied by a copy of the prescription(s) and physician narrative
documentation supporting the medical necessity for the higher utilization." In the
absence of this level of specificity in RMRP, all types of medical records (e.g., physician
progress notes, hospital discharge summary, nursing facility records, home health
agency records, physical therapy assessment, etc.) as well as other types of patientspecific
information (e.g., letter from physician, statement from supplier) is taken into
consideration when we are looking for medical necessity for supply utilization. (An
exception to this is situations where we specifically request copies of medical records, as
is often the case for pre-payment provider review.) Some types of documentation may
carry more weight in terms of the medical review decision than others, such as
information in a patient discharge summary or physician progress note that is
contemporaneous to the date the item is provided may carry more weight than a letter
from a physician written a year after the item is provided.
10. If Medicare is the secondary payor and the Primary payor requires us to bill a concentrator with
the HCPC code E1396 how should we send this in to be processed by the DMERC?
10. The Answer: You would need to use the code that the DMERC requires. The code
E1396 is not a valid code to submit to the DMERC and would not be recognized.
11. Is it acceptable for the physician to answer Question #7 on enteral CMNs, (does the patient have
intractable cancer pain which has failed to respond to an adequate oral/transdermal narcotic
analgesic regimen or is the patient unable to tolerate oral/transdermal narcotics?) with a D or is
Yes (Y) or No (N) required?
11. The Answer: D,Y, or N are all valid answers.
12. If a physician answers question #5 on an external infusion pump CMN as continuous, does
question #6 have to be answered 24 hours for the patient to qualify?
12. The Answer: No.
13. There are no coverage guidelines in the DMERC manual for the following items. Can you please
provide? L8501, trach speaking valve, E0978, Belt, safety with airplane buckle, wheelchair,
A4618, breathing circuits.
13. The Answer: L8501 would be covered per national coverage. E0978 is not a valid code
to submit to the DMERC (Supplier Manual IX page 102). Breathing circuits for use
with a ventilator (A4618) are included in the fee schedule for the equipment rental,
which is in the Frequently Serviced Category. They are separately payable when used
with a patient-owned ventilator (e.g., patient purchased ventilator before Medicare
eligibility) - the claim for A4618 should show that the patient owns the ventilator and
when the ventilator was purchased. The device represented by this code is not used with
nebulizers or oxygen equipment. (See DMERC Dialogue Fall 2000.)
14. When a claim is offset, the specific patients that are offset are not listed on the EOMB, yet when
we call or write in regard to the FCN number that information is readily available. Why isn’t
that information provided on the EOMB to eliminate extra phone calls on both ends. Is this a
possibility to get?
14. The Answer: This information is not available on the EOMB because the system offsets
from the check total amount and is unable to identify the specific case(s) it offset. The
supplier receives an initial demand letter including a list of claims and HICNs that are
a part of the overpayment case. If payment is not received within 30 days of the initial
demand letter, a second demand letter is sent with a copy of the original demand letter.
The money offsets 40 days from the initial demand letter date. The supplier should
retain the overpayment demand letters and match the DCN on the letter to the FCN on
the remittance notice (EOMB) to determine which cases are associated with the offset.
15. If a patient has two ventilators (one is for backup) do they need to be submitted on the same claim
to be paid on the initial submission? We have several patients in which the back up vent is
consistently denied on the initial submission but is always paid through review. What
information needs to be included on the submission to eliminate the review process? (Examples
available if needed.)
15. The Answer: December 1997 DMERC Dialogue explains when we would consider
payment for a second ventilator. However we would never pay for a back up
ventilator. When submitting a claim for a second ventilator you should bill on the same
claim on separate lines .
16. Several patients are a referral from a doctor by the name of Dr Hon. When we try to submit the
claims electronically for these patients the claims are always rejected on the EMC report stating
that it is an invalid physician name. If we have a valid UPIN # why isn’t Dr Hon acceptable? We
have to submit all of these to claim paper. (Examples of reject report available if needed.)
16. The Answer: There are two different front-end rejections: 262- Ord Prv Name Invalid
and 263-Ord Prv Upin Invalid. They both check for different items. The specific edit
was not provided in the question however based on the information supplied it appears
as though the edit received was 262. Please check the format in which the ordering
providers name is entered in your electronic billing software and make sure you are
using the first and last name of the doctor. No abbreviations or titles (such as Dr.,
MD, etc.) should be entered.
17. We have a situation where several physicians work in a clinic setting, and rotate between five
clinics, spending six weeks in each clinic. When we receive an order it could be from Dr. A, who
then rotates out of the clinic where the patient was seen, and now Dr. B is at the clinic. Is it
acceptable for Dr. B to sign the CMN/Rx for the patient? The patient is only seen in one of the
five clinics and the patient’s records are in the one clinic.
21. The Answer: The doctor who signs the CMN needs to be the doctor who ordered the
piece of equipment with the exception of the oxygen CMN . The back of the CMN form,
which says at "Section B," "…While this section may be completed by a non-physician
clinician, or a physician employee, it must be reviewed, and the CMN signed (in
Section D by the ordering physician." Only the HCFA 484 (oxygen) says "…by the
treating physician." For oxygen, both physicians, Drs. A & B could be considered
treating physicians and authorized to complete section D. For other CMNs only Dr. A
(who is the ordering physician) is authorized to complete section D.
Medical Supplies
1. Please provide any additional clarification necessary for billing of gauze for tracheostomy use.
(Laura McIlvaine to follow up with CIGNA staff as a result of the last DAC meeting). Question
to be withdrawn if resolved prior to next meeting.
1. Pending
2. Please review attached examples of claims submitted with HA0 records that do not appear to be
reviewed during claim processing, and provide additional direction to suppliers as to the
information required for electronic claim processing.
2. The Answer: Need HICN in order to research .
3. Please provide any additional clarification necessary for the billing of Iodosorb wound dressing.
(Laura McIlvaine to follow up with CIGNA staff as a result of the last DAC meeting).
3. The Answer: This was answered last DAC meeting.
4. The Regional Medical Review Policy (RMRP) for Therapeutic Shoes for Diabetics specifies a
single code for multiple density insert(s), A5502. There is a large disparity in the quality and cost
of inserts available as well as the reasons for use by the diabetic patient. Is CIGNA aware of
current or future evaluation of items included in this code to evaluate the necessity for further
breakdown of coding? Attached are examples of product information and clinical reference of
different conditions, which might necessitate use of differing products, which covers a wide range
of products currently available.
4. The Answer: We are not aware of any current or future plans to evaluate items included
under code A5502 for possible further breakdown of coding. Social Security Act section
1833(o) limits payment for inserts as follows. We have no authority to increase
reimbursement above these amounts without statutory amendment.
(1) In the case of shoes described in section 1861(s)(12) <1861.htm>--
(A) no payment may be made under this part, with respect to any individual for any
year, for the furnishing of--
(i) more than one pair of custom molded shoes (including inserts provided with
such shoes) and 2 additional pairs of inserts for such shoes, or
(ii) more than one pair of extra-depth shoes (not including inserts provided with
such shoes) and 3 pairs of inserts for such shoes, and
(B) with respect to expenses incurred in any calendar year, no more than the limits
established under paragraph (2) shall be considered as incurred expenses for
purposes of subsections (a) and (b).
Payment for shoes (or inserts) under this part shall be considered to include
payment for any expenses for the fitting of such shoes (or inserts).
(2) (A) Except as provided by the Secretary under subparagraphs (B) and (C), the limits
established under this paragraph--
(i) for the furnishing of--
(I) one pair of custom molded shoes (including any inserts that are provided
initially with the shoes) is $300, and
(II) any additional pair of inserts with respect to such shoes is $50; and
(ii) for the furnishing of extra-depth shoes and inserts is--
(I) $100 for the pair of shoes itself, and
(II) $50 for any pairs of inserts for a pair of shoes.
(B) The Secretary or a carrier may establish limits for shoes that are lower than the
limits established under subparagraph (A) if the Secretary finds that shoes and
inserts of an appropriate quality are readily available at or below such lower
limits.
(C) For each year after 1988, each dollar amount under subparagraph (A) or (B) (as
previously adjusted under this subparagraph) shall be increased by the same
percentage increase as the Secretary provides with respect to durable medical
equipment for that year, except that if such increase is not a multiple of $1, it
shall be rounded to the nearest multiple of $1.
(D) In accordance with procedures established by the Secretary, an individual
entitled to benefits with respect to shoes described in section 1861(s)(12)
<1861.htm> may substitute modification of such shoes instead of obtaining one
(or more, as specified by the Secretary) pairs [168] of inserts (other than the
original pair of inserts with respect to such shoes). In such case, the Secretary
shall substitute, for the limits established under subparagraph (A), such limits as
the Secretary estimates will assure that there is no net increase in expenditures
under this subsection as a result of this subparagraph.
(3) In this title, the term "shoes" includes, except for purposes of subparagraphs (A)(ii)
and (B) of paragraph (2), inserts for extra-depth shoes.
5. The Summer 2000 DMERC Dialogue contains an article entitled "Submitting Additional
Documentation with the Review Request". This article outlines information providers should
submit with review requests for various types of claims. The Medical supply A-Team has the
following questions:
_ The surgical dressings, urological and tracheostomy suction catheter sections include requests
for documentation that is not specified within the respective RMRPs.
_ The Answer: We understand that the information described in the article is not required
by policy to be submitted with an initial claim. The information is provided to aid
suppliers and other billers in determining the type of additional documentation that may
be helpful in obtaining a favorable decision for an Appeals request.
_ The surgical dressing section requests a wound care evaluation dated within 30 days of the
date of service in question. The Surgical Dressing RMRP specifically states that wound
evaluations do not have to be routinely submitted with each claim. Please clarify if this
information does in fact have to be routinely submitted with each claim.
_ The Answer: Documentation of the findings of wound care evaluations are not required
to be submitted routinely with each claim. It may, however, provide additional
information that would be helpful in obtaining a favorable decision for an Appeals
request should the original claim be denied.
_ The urological section includes a request for nurse’s notes and patients’ daily care records.
Please clarify the information and the format that is being sought, with specific information
relative to the "patients daily care records".
_ The Answer: This type of information should be available for patients who reside in
nursing facilities or receive home health agency services. There is no specific format
requirement
_ The tracheostomy section includes a request for documentation of the patient’s condition and
that of the tracheostomy site. Please clarify the information and the format that is being
sought.
_ The Answer: We look for information about the patient's condition that is relevant to the
type and quantity of supplies used. For example, does the patient have respiratory
difficulty, chest congestion, difficulty breathing, increased bronchial secretions? What is
the status of the tracheostomy site? Do secretions frequently accumulate at the
tracheostomy site? Is there drainage from the stoma? Is the stoma healed, inflamed,
infected? We are not looking for the information to be provided in any particular format.
_ Each area outlined in this article includes request for documentation that is not included in the
current RMRP’s, and that appear to be routine documentation requirements for the each of
the areas addressed. Please clarify the authority for imposing additional requirements on a
routine basis outside of the RMRP.
_ The Answer: These are not requirements for billing claims.
_ Will these requirements be outlined in future updates of each of the affected RMRPs?
_ The Answer: We do not believe that suppliers want these to be prepayment
documentation requirements requiring the information to be submitted with every claim
and do not plan to add these as requirements in RMRPs.
_ Will these requirements be imposed on providers in a prospective or retrospective manner?
_ The Answer: N/A
Orthotic & Prosthetic Questions
1. There appears to be broad ranges of codes that are considered similar in the context of a
"previously provided service" denial. For example, a molded body jacket (L0420) will be denied
because a corset style back brace (L0500) has been provided in the past. Which codes are
grouped together for this purpose? Who is responsible for creating and/or maintaining these code
groupings? What is the mechanism for changing these code groupings? If a patient denies in
writing having had the same or similar device, what mechanism is available for the provider to be
reimbursed by the DMERC, if the claim is denied due to a similar service having been provided
by a different provider?
1. The Answer: Codes are grouped according to whether the devices they represent are
applied to the same body part. In your example, both devices are applied to the lumbosacral
area - L0420 to the thoraco-lumbo-sacral area and L0500 to the lumbo-sacral
area. Medical review is responsible for creating and maintaining the code groupings.
Code groupings can and are changed based on a determination by Medical Review that
the existing grouping does not represent same or similar items. Any evidence that patient
has not had the same or similar device should be included with the claim, or in the case of
claim denial, a request for review (Appeals). However, we will also take into
consideration information that is on the patient's claim history, such as if there is a
previously paid claim for the same or similar device. We are awaiting an answer from
our Review Department to clarify if a signed statement from the beneficiary stating
they never had any similar equipment would prove liability to the beneficiary or
whether you would need a properly executed ABN in these cases in order for the
beneficiary to be liable. We hope to have by the DAC meeting in Orlando.
2. Pricing on unlisted orthotic and prosthetic codes is done through a Gap Fill process. However,
many disparate items are included in the same group in order to arrive at an allowable for a given
description. For example, for an unlisted WHFO, the products considered in the pricing
methodology range from simple devices costing $20.00 to complex braces costing many
hundreds of dollars. These different devices have different purposes and rationales for use, and in
no way can be considered to be the same. Is there a way to create more differentiation within the
allowables under an unlisted code? Are the diagnoses or symptoms considered? If not, how can
they be brought into the equation, so that a multi-tiered approach is possible?
2. The Answer: Our medical review department reviews all unlisted orthotic and prosthetic
codes for coverage determination. The diagnoses and symptoms are considered in their
decision. The pricing for the orthotic (splints) are grouped according to the functionality
of the device. If the suggested retail price is $20.00 for WHFO device and functionality is
the same as a $300.00 device, the $20.00 is included in the pricing array for the WHFO.
3. The Region D DMERC appears to be downcoding contracture management orthotics. Where in
HCFA medical policy is there a differentiation between medical coverage for orthopedic / post
surgical versus immobility or neurologically related orthotic therapy coverage for the wrist /hand
/ fingers, elbow, knee, shoulder, or spine? If contracture management orthotics fit the HCPCS
Description, why would the DMERC not recognize them as meeting the definition of the L Codes
(i.e., L1832).
3. The Answer: Differentiation between medical coverage for orthopedic/postsurgical versus
immobility or neurologically related orthotic therapy coverage for the wrist/hand/fingers,
elbow, knee, shoulder, or spine is not addressed specifically in HCFA medical policy. The
SADMERC and DMERCs have determined that many devices whose purpose is
contracture management do not fit the HCPCS description of specific L codes and have
coded these devices under appropriate NOC codes (e.g., L2999). In those cases where
contracture management orthotics do fit the description of specific L codes, the specific L
codes are used for billing claims.
4. All orthotic and prosthetic codes are being subject to the "five year replacement" requirement, yet
many of the codes are for devices that have a much shorter life expectancy due to their material or
purpose. For example, a brace made from a cloth or elastic material will obviously not last
through five years of wear and washing, or a fracture brace provided for an injury is not
appropriately used on a subsequent injury several years later. Does the DMERC agree that there
are problems being created with the recurring denials and appeals that result from this policy? If
so, what support can be given in an effort to refine this policy to reduce the unnecessary
paperwork burden on both the DMERC and providers?
4. The Answer: As you know, the minimum 5-year useful lifetime rule is established by
legislation and HCFA policy. The DMERC selects some orthotic claims for pre-payment
complex (medical record) review when there is an indication of more frequent
replacement. We are aware that many of the claims selected for review are denied and
subsequently appealed and are in the process of reviewing data related to these cases.
We believe that this is sometimes due to failure of the supplier to provide requested
documentation within the specified timeframe (30 days). We have recently increased the
total time allowed for receipt of the requested documentation to 45 days from the date
our letter is generated by the system. We expect this change to better accommodate
delays in receipt of documentation due to mail time. We are also open to any comments
or suggestions that you have with regard to this issue.
Rehab Questions
1. We understand that the supplier is responsible for knowing what should and shouldn’t be
reimbursed and that we are also responsible for communicating that to the beneficiary. What are
the guidelines in determining the reimbursement potential of the CMN with clinical notes? Are
you suggesting that the DMERC will override the doctor’s signed Certificate of Medical
Necessity if the DMERC does not agree with the notes provided?
1. The Answer: In HCFA Ruling 93-1-1 it is noted that :
[i]n the vast majority of cases, if the attending physician’s certification of the medical
need for the services is consistent with other records submitted in support of the claim for
payment, the claim [ ] is paid. However, if the medical evidence is inconsistent with the
physician’s certification, the medical review entity considers the attending physician’s
certification only on a par with the other pertinent medical evidence. Region D has the
obligation to examine the entire medical record in support of claim payment.
2. Per the Region D Supplier Manual, chapter 9, page 51-53, in the documentation section, it states
"a certificate of medical necessity which has been filled out, signed and dated by the treating
physician, must be kept on file by the supplier." This is the only documentation required from
the physician prior to submission of claims, per the manual.
a. Why would your request for clinical notes not be directed to the doctor? How can the
supplier community interpret these records and determine if a claim should be submitted
with or without an ABN the beneficiary explaining why it should or shouldn't be paid?
2a. The Answer: MCM 4105.2 specifically instructs the carrier "if necessary for your
medical necessity determination, ask the supplier to obtain documentation from the
treating physician, establishing the severity of the patient’s condition and the
immediate and long term need for the equipment and the therapeutic benefits the
patient is expected to realize from its use."
b. Is the information contained the clinical notes not confidential between the doctor and
patient?
2b. The Answer: When the beneficiary signs field 12 on the HCFA 1500 form or a
Signature on File form they are giving permission to obtain medical records to
process the claim .
c. Does the supplier have the right to view these documents which we believe are private
and confidential information of the doctor and patient?
2c. The Answer: See previous answer for 2b. In order for a supplier to provide the best
equipment choice possible for a patient they must be fully aware of all the issues
involving that patient. A proper intake/form will provide the patient with this issue
of obtaining medical information. Again, when the beneficiary signs their signature
to give you permission to send the claim to Medicare they are giving permission for
you to obtain the medical records to process the claim.
In addition, physicians are required to provide those medical records under the
authority of the Social Security Act Section 1842(p)(4). This section provides that:
[i]n case of an item or service…ordered by a physician or a practitioner…but
furnished by another entity, if the Secretary (or fiscal agent of the Secretary)
requires the entity furnishing the item or service to provide diagnostic or other
medical information in order for payment to be made to the entity, the physician or
practitioner shall provide that information to the entity at the time that the item or
service is ordered by the physician or practitioner.
d. Do you expect the supplier community to interpret doctor's clinical notes and potentially
overrule a doctor's signature on a CMN?
2d. The Answer: Medicare requires that the person billing for their service ensure that
the service is "reasonable and necessary." Suppliers of DMEPOS are healthcare
professionals and should at least be familiar with the products they provide, policies
of the DMEPOS items for which they bill, the criteria within the policies and the
common medical conditions for which the DMEPOS is provided. Just as I would
not publicly put myself forth as a tax attorney without any knowledge of tax law,
DMEPOS suppliers cannot plead "medical ignorance" of the conditions for which
their products are prescribed. In certain situations, the supplier may even be more
familiar with the item or service being provided than the physician. Bottom line:
The supplier is billing Medicare for the service; therefore, the supplier is liable
determining whether or not medical necessity has been met. If the beneficiary does
not appear to meet Medicare medical necessity guidelines, we suggest a proper
Advance Beneficiary Notice be obtained.
3. Per the Region D Supplier Manual, Chapter 7, pages 4-5, it states "There must be clinical
information in the patients 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 documentation in the patient’s medical
record does not have to be routinely sent, to the supplier or to the DMERC. However, the
DMERC may request this information in selected cases. If the DMERC does not receive the
information when requested or if the information in the patients 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."
3a. How can the supplier community, who has not been seeing the patient regularly like
the doctor read the notes obtained and determine the medical necessity?
3a. The Answer: See answer to 2d.
3b. Should a supplier issue an ABN on every claim that requires clinical notes?
3b. The Answer: No, you cannot provide a blanket ABN. There must be a specific
reason for suspecting that the beneficiary does not meet Medicare criteria and that
specific reason should be communicated to the beneficiary in the ABN.
3c. Can a supplier issue an ABN on every claim where clinical notes are required?
3c. The Answer: The supplier is held liable for the products and services delivered
based upon the signed CMN and Clinical notes.
3d. The supplier is held liable for the products and services delivered based upon the
signed CMN and Clinical notes. Is the doctor held liable for a signed CMN that is
overturned by the DMERC’s interpretation of his/her clinical notes?
3d. The Answer: The physician did not file the claim for payment. However, if a
physician were found to be falsifying a CMN we would refer to our Anti-Fraud unit
to notify the local Medicare Carrier in the state he/she is submitting his/her
physician claims.
3e. At the DMERC, are the clinical notes reviewed by a registered nurse or licensed
physician?
3e. The Answer: Could be either or both. For example, some types of claims that
require clinical documentation may only be denied by the medical director.
4. In an attempt to provide clear, concise information, and having been given several responses that
differ, please assist me with my dilemma. The issue is in regards to, the initial date, and the
repair of patient owned durable medical equipment, when Cigna does not have a CMN on file.
Shelly instructed us to always use the Medicare effective date, even if patient had Medicare
coverage at the time of service. When asked the same question, Troy and Ty stated, if the item
was provided before Medicare entitlement, use beneficiaries Medicare effective date. They
further added, "If the item was funded by another insurance and patient was Medicare eligible, to
use the date of service." During both conversations, when asked, they could not direct us to
documentation that supported their responses. Please direct us or add clarity.
4. The Answer: Refer to DMERC Dialogue Fall 2000 page 9 question 4. In this case the
initial date on the CMN is not necessary. The CMN is only used to see if patient meets
Medicare’s criteria for the equipment. The date of purchase is necessary.
Respiratory
1. The DMERC Supplier Manual states that when portable oxygen is added to a patient who is
already using a stationary oxygen source, a "Revised" CMN is required. If the situation occurs
where the patient is using portability only on the Initial and the physician adds the stationary
source, does the supplier need an "Initial for the stationary source" or a "Revised of the Initial
which was for the portable source only"? If an Initial for the stationary is the answer, is re-testing
required?
1. The Answer: It would be the same as when a portable is added at a later date. We would
need a revised CMN for the stationary.
2. Suppliers understand that Medicare guidelines prohibit Suppliers from changing the CMN after
the physician signature and also that all changes must be signed in full and dated by the
physician. However, in the case of a Recertification or Renewal on which the Initial date is not
listed, can the Initial date (which has already been established with the DMERC) be added by the
Supplier after the physician has signed without a return to the physician? Also, if it is discovered
that the HICN has been typed incorrectly on the CMN can it be corrected without returning to the
physician?
2. The Answer: If anything is changed or added after the doctor has signed the CMN the
doctor would have to sign the change/addition in full.
3. Patient receives oxygen on 2-19-00, modality is concentrator, initial CMN qualifies and HCPC’s
are for E1390 only. Claims are transmitted electronically. Patient switches to liquid system on
June 23, 2000. Patient receives portable system. According to Summer 2000 updates a "Revised"
CMN is required for portable system (CMN sent and received).
3a. How is CIGNA going to process the liquid stationary system since the original CMN has
a code of E1390? (The Summer 2000 Update indicates a new or revised CMN is not
needed when there is a change of modality).
3a. The Answer: No CMN needs to be sent. Our system will update our records as long as
the CMN for the E1390 is current. The DMERC makes a determination based on need for
oxygen therapy. If a modality changes the supplier would need to get a new order but
neither a new CMN nor a repeat blood gas study are required. We will set our records
for the liquid in this scenario up to pay with the initial date the same as for the
concentrator and the recertification will not change.
3b. Will the claim deny for no CMN because according to CIGNA Customer Service this edit
is first in the process line up and will deny before reaching the HA0 field?
3b. The Answer: See answer to previous concern.
3c. Since the portable was not ordered with the original stationary unit and according to the
Summer 2000 Updates an initial CMN is not required for the portable, a Revised CMN is
now acceptable, when the patient recertifies after one year, can the Doctor now recertify
the patient for his stationary and the portable system back to his original date which in
this example was 2-19-00 recerting 2-19-01?
3c. The Answer: The portable, if added at a later date than the stationary, will be able to be
recertified at the time the stationary system is recertified.
3d. Can the CMN be completed with all or no HCPCS in section A and then list the various
modalities in section C?
3d. The Answer: In answer to your question if the CMN can be completed with all or no
HCPCS in section A and then list the various modalities in section C the answer is no.
Recently, it has been brought to our attention from the CMN auditor that suppliers are
leaving the HCPCS codes off of section A. This is a non-compliance issue. In addition
section C is not being completed at all or correctly. This is also a non-compliance issue.
We want to make it clear that section C MUST be completed prior to sending the CMN to
the physician so that a ‘checks and balance’ system is achieved. The physician can see
what is being supplied and what it is costing his patient. The old 484 form did not have a
place where the HCPCS codes were entered but the new form does have that information.
A supplier cannot list every oxygen code to cover this requirement so they do not have to
get a new order when a modality changes over time.
Maintenance
1. A recent review request asking to begin a new capped rental period was denied due to the fact
that an estimate for cost of repair was not included. Does a capped rental replacement after the
item has reached the useful lifetime five year usage and is on maintenance, require an estimate of
cost of repair? Chapter VI of the DMERC Supplier Manual does not specify this requirement.
1. The Answer: Just because a DMEPOS item has reached five years usage does not
warrant an automatic replacement of the item. We need some type of proof that the item
has had regular maintenance and now is beyond repair. That is the reason we need a
cost estimate of the repairs. Refer to DMERC Dialogue Winter 1998 page 8 concerning
the replacement of DMEPOS.
2. Medicare guidelines state that Suppliers are obligated to notify beneficiaries in the 10 th month of
rental of an item in the capped rental category and to submit billing in the 11 th month with the
appropriate modifiers appended. After the notification period of time has passed for response by
the beneficiary regarding a desire to purchase, rent is billed through the 15 th month and the item
goes into maintenance. When the beneficiary calls several months/years later and expresses a
desire to purchase, it is the supplier understanding that they are under no obligation to offer that
purchase on a retroactive basis. However, when the beneficiary contacts the beneficiary line at
the DMERC they are advised to have their supplier refund months 14 & 15 and all maintenance
to convert to purchase. How should the Supplier respond to the beneficiary who calls and requests
such a purchase?
2 . The Answer: We would not change in this situation. Once the modifier is sent to the
DMERC it cannot be changed unless in very specific circumstances. Such as, if a
beneficiary states they never received a letter from the supplier and on request the
supplier has NO documentation of the beneficiary receiving the letter. Or a beneficiary
states they choose a different option than what the supplier submitted to Medicare and in
checking the supplier’s records that is verified. This would take special handling and is
only done in rare cases.
3. We are getting conflicting information from Cigna on how they calculate when a piece of
equipment goes into maintenance. We are sometimes being told that 15 months have to be paid
& other times we are told it is calculated from the initial CMN date. How do we handle when the
patient switches from another company & the previous company didn't bill all 15 months?
3. The Answer: Please refer to the most recent DMERC Dialogue Fall 2000 pages 6 & 7.
It states paid claims. In the case when a previous company has not billed we may look at
this on a claim by claim basis.
4. On the past maintenance problems, the collectors are seeing that current maintenance claims are
being paid, however, they did not see where they went back & reprocessed all of the past old
claims.
4. The Answer: Please refer to the DMERC Dialogue Fall 2000 article on pages 6 & 7. If
after research, you find an MS claim was denied in error and has not been adjusted for
payment, resubmit the claim. The claim must be submitted within the time limits for
filing.
General Questions
1. Can the DMERC provide Suppliers with an updated list of which remark codes must go to
Review and when to Adjustments? (see attached document with previous remark codes)
1. The Answer: CIGNA has no plans at this time.
2. What are the advantages to becoming a participating provider with Medicare? For participating
Suppliers, can you provide a list of information that Medicare Customer Service representatives
should be able to provide during a phone inquiry from the Supplier?
2. The Answer: MEDPAR list and Medigap crossovers are two advantages of being a
participating supplier. They can also access patient deductible and claims status
information over the Interactive Voice Response (IVR) system. In addition, if you are an
electronic biller you have the option of getting software to access beneficiary eligibility.
Questions from previous DAC meetings
1. From the Questions for Comment from the May 4, 2000 DMERC Advisory Committee
meeting, question #17 addresses re-evaluation of the patient. What information is required to
be included in the re-evaluation, particularly those that do not require re-testing? What is the
expectation for Suppliers to monitor the re-evaluation?
1. The Answer: Dr. Hoover already answered this in his follow-up memo on May 9 th . It
was: The DMERC does not specify what is involved in the treating physician’s reevaluation
of a patient and their need for oxygen therapy. This is determined by the
treating physician’s clinical judgement and the medical standard-of-care for that
community. The re-evaluation may or may not involve a repeat arterial blood gas or
oximetry test unless required by Medicare coverage guidelines. The DMERC will be
looking for evidence that the physician saw the patient, considered the benefit
received from the oxygen and assessed the continued need for the oxygen therapy.
2. PRIOR AUTHORIZATION and CLEAN CLAIM DOCUMENTATION
As briefly discussed during our meeting at Med Trade West in Las Vegas, year 2000, Dr. Hoover
suggested the DMERC was looking into formatting a preauthorization process for CUSTOM
WHEELCHAIRS and related equipment. (Until pre-authorization becomes an accepted policy,
we posit this format and question pertains to an acceptable "Clean Claim" format as well)
The DAC committee offered its assistance in the process and believes it may be beneficial to
create an outline of potential documents and requirements involved in the process. Suggestions
include:
_ Appropriate CMN completed accurately and appropriately
_ Letter of Justification to include client history, current condition, environmental
considerations, neurological information, orthopedic information, range of motion,
measurements. This letter will be signed by the Physician, Therapist, and Certified Rehab
Technology Provider.
_ Goals and anticipated Outcomes
_ Detailed list of current equipment
_ Detailed list of new equipment
_ Prescription
_ Manufacturer Catalog pages
_ Completed HCFA 1500 form(s)
While the form, sequence, and specific contents are a matter of significance, what other items, if any,
would you consider standardly necessary for pre-auth and claim payment of a CUSTOM
WHEELCHAIR?
2. The Answer: Maybe estimated time from specifications to delivery.
3. Another topic of discussion during our meeting at Med Trade West in
Las Vegas, year 2000 surrounded extending the length of time a CMN would remain valid. What
is the current status/plan for extending the expiration timeline?
3. The Answer: Still under discussion with HCFA.

Medicare Region D – DMERC Advisory Committee
May 4, 2000 Meeting
Questions for Comment by CIGNA
Provider Enrollment
1. We recently had a new start up, we did everything "exactly by the rules"; as far as applying
for Medicare Provider #, etc with NSC. We had a Site Visit by Choice Point at the new
location, and we were informed of our new provider number with Medicare within a week
after the Site Visit (by NSC). We opened for business, started submitting claims to
Medicare, etc. and were not getting paid; we had also been told that our new location would
receive a new, updated Medicare Manual (Region D) as soon as we had a provider number.
This never happened either, so we called Region D and we were told that CIGNA did not
have on file that we had a Supplier Number! Our question: what is usually the process and
where did this communication between NSC and CIGNA DMERC breakdown? It is very
frustrating and certainly affected our cash flow (or lack thereof!) (I will ask this same
question of a representative from NSC at an upcoming Association meeting).
The NSC downloads a file with all changes and additions and sends the file electronically to
CIGNA daily. The updates are then applied to the claims processing system. This
information was verified with CIGNA’s NSC Specialist and Natalie Castro (NSC – Supplier
Relations Specialist). Supplier Manuals should be received with 6-8 weeks of enrollment.
The Supplier Manual can be accessed on the website at www.cignamedicare.com.
Please provide the company name, supplier number, contact person and telephone and I will
research this specific case.
2. Does CIGNA plan to bid for the Region A contract, since that carrier is not re-contracting
with HCFA?
HCFA will retain four DMERCs and will not allow one of the three remaining DMERCs to
bid on the contract.
Policy
Policy Area: Proof of Delivery, Region D Manual, Section VII-5&6
3. The DAC has had a number of questions from providers regarding the New Proof of
Delivery section listed above. We would like to provide general information about how
Home Infusion Pharmacies, and HME companies provide I.V. and PEN products to their
patients, and how they bill Medicare for these products.
When the patient begins service with one of these providers, the original shipment date
matches the initial billing date for service. However, future shipments of product will be
delivered up to several days prior to the patient running out of drug or PEN, because the
patient cannot afford not to have the drug or PEN item. The provider bills Medicare for the
quantity used during the months billing period, based upon the physician order for the
patient, and not necessarily what was delivered, which is often a greater quantity than the
physician order. This practice has been occurring since the External Infusion and PEN
Policies were begun.
We would request that CIGNA open discussions with the DAC and HCFA, to review this
policy. Providers want to insure that their patients do not run out of critical drugs or PEN
products, and that they are in compliance with Medicare policies.
This request/comment will be forwarded to Jim Underhill.
Delivery of Supplies
4. Please clarify who is considered an "authorized representative" of the beneficiary for the
purpose of signing:
Release of information - The request may be signed by a representative payee, legal
representative, relative, friend, representative of an institution providing the enrollee care or
support, or of a governmental agency providing him assistance. Medicare Carriers Manual
3057.
Assignment of benefits - (same as above)
Proof of delivery – (same as above)
5. What is required to be documented on each of the above forms? Are all the elements of the
following information required as an "authorized representative?
Beneficiary Name – required per Medicare Carriers Manual 3008.
Signed "by" – required per Medicare Carriers Manual 3008.
Authorized representative’s name - required per Medicare Carriers Manual 3008.
Relationship to the beneficiary - required per Medicare Carriers Manual 3008.
Address of the authorized representative - required per Medicare Carriers Manual 3008.
Telephone number of authorized representative – not required.
In addition, the authorized representative must provide the reason the beneficiary can not
sign. Medicare Carriers Manual 3008.
6. If all the above are required items, can the provider have the authorized representative sign a
one-time form containing the information, so that each document does not have to contain all
the above listed elements?
Once the supplier has obtained the patient’s one-time authorization, later claims for those
same services can be filed without obtaining an additional signature from the patient. These
claims may be on an assigned or nonassigned basis with the exception of durable medical
equipment rentals. The one-time authorization for DME rental claims is limited to assigned
claims. Authorization must be renewed if a new item is rented or purchased. Supplier
Manual IV page 18.
Clarification – Proof of delivery and signature on file are two separate documents.
7. Is an UPS/FedEx package signature an authorized signature for verification that a beneficiary
received the goods? If this were ok, would this type of signature be a problem in a postpayment
audit, considering it has no other elements?
When the supplier is using Method 2 – supplier utilizing a delivery/shipping service to
deliver items, acceptable proof of delivery would include the delivery service’s tracking slip
and a supplier’s shipping invoice. An authorized signature is not required. Supplier Manual
VII page 5.
Medical Supplies
8. What can be done to improve the correct processing of claims using information contained in
the HA0 comment field on electronic claims? Information contained in this field is routinely
overlooked causing a significant number of claims to deny or underpay. Upon receiving a
phone call, the information is confirmed by CIGNA to be included in the record and the
claim can be adjusted. However, this adjustment can take up to 45 days. Routine requests to
correct claims processing create unnecessary burdens on providers needing staff time and the
increase of outstanding accounts receivable. May we request a commitment by CIGNA to
review this situation within their system and develop an effective plan that will address this
area of claims processing. (Several examples are attached for demonstration of initial
denial/underpayment only. Some may have subsequently been adjusted and are no longer
pending).
See Attached Example Set #1
Information was sent in the HA0 record but it was not the information specified in the
DMERC Dialogue Summer 1998 pages 5-6 or the Supplier Manual IX 87.2.
Wheelchair Claims
9. As many claims are returned with denial code C016, "claim lacks information which is
necessary for adjudication", C042, "charges exceed our fee schedule or maximum allowable
amount", or C050, "these are non covered services because this is not deemed a ‘medical
necessity’ by the payor", could CIGNA please identify where providers can find coverage
criteria (explicit information requirements) for the following codes:
K0005, K0010, K0011, K0012, K0008, K0009, K0014, K0108, E1399
See Attached Example Set #2A, 2B, 2C
2A,beneficiary #1 - The first time the claim was submitted the CMN was not dated. 2 nd
submission, the initial date was 11/01/1998 and the signature date was 08/28/1998. Per
claim progression provided by supplier, the CMN was not even sent to the doctor for
signature date until 11/20/1998. How can this be?
2A, beneficiary #2 – The first submission was denied "lacking information", since the CMN
was signed 04/26/1999 and the initial date of need was 11/30/1999. How can the physician
indicate that the patient will need the item for a future date (in this case, 7 months in the
future)? The claim was submitted again and denied not medically necessary. Once the claim
has been denied not medically necessary, the claim must be sent to review.
2A, beneficiary #3 – CIGNA pulling the original claims for further research.
10. Adjunct to question 1, where can a provider find quantifiable information detailing why a
claim is downcoded or denied when a completed CMN, equipment assessment signed by
physician, therapist, and provider endorses the need for the specific equipment.
See Attached Example Set #3
CIGNA pulling the original claims for further research.
11. Referencing the DMERC Advisory Committee meeting of February 9, 2000, the answers to
question 15 and question 27 both address wheelchair repairs. The Summer Dialogue of 1998
is quoted in both answers. As the answers appear to be dichotomous, can you please clarify
your position on this subject?
Does Medicare pay for modifications and/or repairs to patient owned equipment that was not
originally purchased by Medicare, but in fact, meets medical necessity standards set by
Medicare?
See Attached Example Set #4
Yes, Medicare does pay for repairs if Medicare paid for the item or the item met coverage
guidelines and the appropriate documentation is attached as indicated in the Summer 1998
DMERC Dialogue.
In the example, the beneficiary was Medicare eligible (Medicare was primary) at the time the
wheelchair was provided. The claim was billed as a K0005 with no CMN. Without the CMN
there is not enough information to make a determination. Since Medicare did not participate
in the purchase of the wheelchair, Medicare will not participate in the repairs of the
wheelchair. In addition, payment is now being requested for repairs for a K0004. Is this the
same wheelchair?
12. Clarify the connections between the physicians chart notes and the
Certificate of Medical Necessity for the coverage of a Power Wheelchair
(K0011) since both are reviewed for medical necessity of the item.
Certificates of Medical Necessity are OMB-approved forms and are summary documents
used for the collection of medical necessity information. Section B asks for answers to
questions regarding the clinical status of the patient and their physical capabilities.
Therefore, it is expected that the medical record substantiate the information provided on the
CMN summary document. As such, the DMERC may request medical records to confirm that
the answers provided on the CMN are an accurate reflection of the patient’s condition.
13. When attachments are sent with manual claims, how can suppliers ensure
that the documents stay with the claim when filming in the mailroom and the
claims reviewer can retrieve them for review later?
Processes are in place to ensure attachments are NOT separated from claims in the
mailroom. The entire claim is mircofilmed before the claim is keyed into the system. In the
event that a claim is denied and the supplier believes that justification was attached, the
supplier may request that a customer service rep pull the original claim and attachments.
14. When a denial is received for same or similar equipment, where do we
send the document from the previous supplier indicating that this equipment
has been picked up? Should this be sent in as a review or a resubmission
through the adjustment unit?
This should be sent to the Review Department PO Box 22995, Nashville, TN 37202 .
15. A patient receives a wheelchair for 3 months with diagnosis
osteoarthritis. The wheelchair is returned when the patient's health
improves. One year later a different wheelchair (same HCPCS) is delivered
with a new diagnosis of COPD, Congestive Heart Failure, and fractured ribs.
The claim was adjudicated to start the capped rental period at the end of
the initial rental period over a year ago even though there had been more
than a 60-day break in service and a significant change in diagnosis. The
provider included the delivery and pickup slips, the old and new CMN, and
claims. Why was this claim paid as such and why the additional information
was needed?
See Attached Example Set #5
CIGNA pulling the original claim for further research.
Respiratory
16. The winter 1999 DMERC Dialogue (page 4) states that group 1 or 2 oxygen patients must be
tested within 30 days prior to the date of re-certification if the initial certification specifies
the length of need less than lifetime. However, the region D Medical Policy on oxygen (page
1x-67) states, "initial certification and 3 month recertifications required because of initial
PO2 of 56 mm hg or greater or oxygen saturation of 89% or greater must include the results
of a recently performed ABG or oximetry test. For other recertifications, retesting is not
required." Please clarify when re-testing is required (e.g. for a CMN with an initial length of
need >4 months or < lifetime).
All beneficiaries qualifying for Group II must be re-tested. In addition, if the estimated
length of need on the initial CMN is less than lifetime and the physician wants to extend
coverage a repeat blood gas study must be performed within 30 days prior to the date of the
revised certification. This does not change the recerification requirements.
17. The winter 1999 DMERC Dialogue (page 4) states for group 1 and group 2 oxygen patients,
the patient must be seen and re-evaluated within 90 days prior to any recertification date.
Could you please clarify requirements of an evaluation:
Can only the treating or ordering physician re-evaluate? yes
Can a home health agency, HME provider, etc. re-evaluate; send results to physician, obtain
his/her signature and review date? no
Does a re-evaluation require retesting? If yes, can the HME provider perform the re-test?
No. The Supplier Manual states the "initial claim" must include results of blood gas study
that has been ordered and evaluated by the attending physician. Regarding physician
evaluation for recertification, if the length of need is less than lifetime a new test and reevaluation
would need to be completed. A DME supplier is not considered a qualified
provider or supplier of laboratory services for the purpose of these guidelines. These
guidelines do not pertain to re-testing. Yes, these guidelines do pertain to re-testing.
How will the DMERC determine in a post-pay audit that re-evaluation requirement has been
met (e.g. physician notes). Medical records will be reviewed.
18. In order for a BiPAP unit to be covered a CPAP unit must be tried and failed. Please clarify
requirements of "tried and failed."
Scenario: If polysomnography is started with a patient on room air and the patient exhibits
30 episodes of apnea, lasting ten seconds, in a period of time less than 6-7 hours of sleep.
Then the patient is titrated on CPAP, but still exhibits apneas. The patient is then switched to
BiPAP and stabilized. In this scenario, is the CPAP considered "tried & failed" and is the
provision for using the BiPAP met?
In the scenario described, CPAP has been tried and failed. BiPAP provision met.
19. Should the sleep lab or the physician document CPAP failure? Is a signed document from
the physician adequate?
A detailed statement from the physician is adequate. OSA patients must have tried CPAP
and failed to achieve therapeutic benefit or were unable to tolerate the pressures associated
with the single level device .
20. The rule states that the physician must have considered CPAP & rule it out before a BiPAP
will be approved. Does this mean that the patient has to have tried CPAP in their home &
failed, or is it enough that the physician documents the diagnosis is not Obstructive Sleep
Apnea (OSA) and therefore, CPAP will not work?
For COPD patients, there must be an indication from the physician that OSA is not
contributing to their sleep disordered breathing. This may be accomplished by a
polysomnogram but it is not required unless clinically indicated. Ruling out OSA is a
clinical decision; therefore, the records of the physician should contain documentation of the
rationale for the decision.
21. If a CPAP mask will not fit properly, thus a BiPAP mask is required, qualified as "tried and
failed" and thus approval of BiPAP appropriate?
The DMERC is unaware of a mask for a bi-level pressure device that would not also work
with a single level device.
22. Please provide the DAC information on the status of revision to CPAP policy. Is the new
policy expected to include hypopneas or other events (e.g. central or mixed apnea)?
The medical directors are working on a revision to the CPAP policy; however, they are early
in the "fact-gathering" process. The new policy will take hypopneas, in addition to apneas,
into consideration.
23. Medicare purchased a CPAP for one of their patients in 1988. They are now trying to bill for
supplies. Medicare is requesting a DMERC CMN for the CPAP. We understood the policy
to be, if the medical justification has already been established with Medicare, a DMERC
CMN is not required, a standard CMN will be sufficient for supplies. Can you please clarify
with Medicare if this policy is correct.
The following documentation would be required:
_ A statement explaining why Medicare did not pay for the equipment that the supply is
being provided for
_ Certificate of Medical Necessity (DMERC OMB approved form)
_ Date of purchase
_ Type of equipment supply will be used with
Old Business
Maintenance & Service
Would you comment on the documentation that was used to deny all of the maintenance (MS)
claims? If it was the DME provider manuals are you sure it supports your conclusions to
suspend payment from providers? Can you identify the exact language and point to the
terminology that says, "if we don’t pay 15 months of claims, we will not pay for maintenance?"
Here is the reference from the Medicare Carriers Manual stating the 15 rental months must be
paid in order to allow payment for maintenance and service.
5102.1. Methodology for Calculating Fee Schedules.
Payments During a Period of Continuous Use.--Rental payments may not exceed a period of
continuous use of longer than 15 months. After 15 months of rental have been paid, the supplier
must continue to provide the item without any charge, other than for the maintenance and
servicing fees until medical necessity ends or Medicare coverage ceases (e.g., the patient enrolls
in an HMO). For this purpose, unless there is a break in need for at least 60 days, medical
necessity is presumed to continue. (See subsection 4.) If a supplier makes any additional
charges, contact the RO of the Inspector General in accordance with Section 14032.
This was information was noted:
DAC minutes 07/14/1999
DAC minutes 10/12/1999
DMERC Dialogue Fall 1999 page 3
DMERC Dialogue Spring 1999 page 3
Providers were initially told that the Maintenance and Service project should be completed by
3/31/00. However, we have not yet seen payments on these denials. Additionally, posted on the
CIGNA Website is an article addressing the M & S denials, stating that the claims lines have
been identified and that the supplier doesn't need to resubmit any of these claims. We have
received direction from the Customer Service line (Pam Schultz 3/13/00, confirmed with Sup
Susan Curtis) to research and resubmit any of the claims to the adjustment department. Which
advice is correct?
CIGNA estimated April 1 as a completion date for this project. This project is being done on
overtime and by persons with a certain level of expertise.
In the article posted on the website, it states "suppliers need not contact our office for claims to
be reconsidered" because suppliers were sending lists of M&S denials for claims that met the
M&S project criteria, causing duplicate efforts/work and thus slowing the completion of the
project. Customer service will honor requests for individual claims to be adjusted, especially if
there is urgency involved, but Customer Service will not accept lists of claims for review from
suppliers. M&S denials that are not included in the M&S project should be researched by the
supplier and a request sent to adjustments or review.
An update on the progress of the project:
5497 total
3049 completed
966 need further review
Carlos Reyes has scheduled a conference call with Tricia Luna for April 26, 2000 to discuss this
issue further.