Region D DMERC Advisory Committee
Questions to CIGNA Medicare
For Review at the October 30, 2002 Meeting
Georgia World Congress Center
Atlanta, GA
Final Q & A to DAC sent 10/24/02
ADMC Questions
Follow-up to Request for Input from Rehab A-Team
1. Once an affirmative confirmation on an ADMC claims has been rendered, the product has
been provided to the beneficiary, then the claim is submitted to CIGNA for reimbursement.
One problem has been denials due to the lack of product numbers on K0108 items. Some
manufacture
s
do
ue
not use product numbers, order forms have been provided showing the
origin of the charge, yet those documents did not suffice.
Question
:
What does a provider do
when the manufacture does not utilize product numbers?
Answer
: Please provide examples to Dolly.
The ADMC is a coverage determination only, it does not extend to the price that Medicare
will allow for the item(s). Payment amounts are determined upon receipt of the claim. Claims
must include the manufacturer name, model name/number, and suggested retail price of the
wheelchair base. Also, items billed with HCPCS K0108 must include a narrative description,
manufacturer name, model name/number, and the suggested retail price. Order forms/price
lists are accepted as sources in place of the above referenced material. When submitting an
order form/price list, clearly reference the description for each item with a direct reference to
the item on the order form/price list.
2. ADMC is a process, typically in which, the claim is laden with letters of justification,
CMN’s, documentation from Manufactures, retail price structure and other forms of
justification for the items being pursued. The volume of documentation required, limitation in
both code sets, and in the HAO field, many of these claims are being sent via mail and not
electronically transmitted. Currently these packets of data are submitted for the ADMC
process and then again when the claim is submitted for payment.
Question
:
Why is there not a way to assign a case number to these packets of data or other
means to control the documents at CIGNA and relieve the provider from submitting this data
twice? Secondly with the limitations in the code sets and HAO field what is being done to
improve the electronic transmission for these claims?
Answer
: A case number is assigned for each ADMC. Since ADMC does not determine the
pricing of the items, it is the supplier’s responsibility when submitting a claim to give the
information needed to adjudicate it properly. There may be a way to do this. We will
consider your suggestions and work on a method to accommodate your proposal.
The HA0 record for claims submitted in the NSF format allows for 281 characters.
2
The Health Insurance Portability and Accountability Act (HIPAA) law named the ANSI X12N
837v.4010 as the standard to be used for Professional claims. As you know, the entire health
care industry is moving to this format. This standard limits the number of characters that can
be submitted as free-form text to 80 characters at the line level, and 80 characters at the
claim level. This requirement is set by the ANSI X12N committee and not CIGNA Medicare,
CMS, or the Medicare program. These standards were developed by input from payors,
providers, suppliers and vendors and can only be changed by presenting a valid case to the
workgroup and committee responsible. Changes may be recommended through www.hipaadsmo.
com. Code sets which are named in law or the implementation guides are maintained
by specific organizations who are named in the implementation guides or in law. This is
another case where not all of the code sets are Medicare code sets, however they may be
required by the standard.
3. Dealers in Region D have reported difficulty with claims where a power tilt system is
provided after a manual recline system was previously provided. These claims are being
denied as same or similar. The medical necessities for the two systems differ significantly,
yet the two are viewed as the same.
Question
:
What might CIGNA suggest to these providers, to educate them on how CIGNA
views the difference in these two systems.
Answer:
Suppliers should provide medical justification for the additional feature of tilt
versus recline only. In addition, there must be justification for the power versus manual
feature. CIGNA is aware that power tilt/recline combinations are not the same as manual
recline; however, without additional information to describe the medical necessity for the
addition of power and/or tilt (or the change in medical condition that requires upgrade to a
power tilt/recline system), same or similar denials are likely to occur.
4. We have noted instances where an item is approved on the ADMC, however, when the item
is billed, we receive a medical necessity denial. We have noted that a call to CIGNA usually
can correct the error. We feel that this should not be happening and takes up time for all
involved. Can closer communication be initiated between the ADMC and the billing
processes to avoid this type of denial?
Code K0016 was approved on initial ADMC but denied on claim with a PR-50 (Not
medically necessary).
Answer:
Medical review is revising their process for entering ADMC CMN information into
the system to address this situation. Thank you for bringing it to our attention.
We have noted instances where the codes have been changed from those on the CMN or
additional codes have been added. Do we bill as changed or noted on the ADMC?
Code K0113 is addressed on CMN as a chest support. It is addressed on the ADMC as a
K0108.
ADMC request as noted on the CMN requests K0064 – flat free inserts. The ADMC
authorization is approving K0064 (correct code) and K0069 rear wheel assembly. The K0069
was not on the CMN. What does the notation of "correct code" refer to?
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Answer
: When the code shown on the ADMC response letter is different than the code shown
on the CMN provided with the ADMC request, we intend that you use the code shown on the
ADMC request on the claim. You should also have the CMN revised accordingly. K0113 was
a code for a vest-type device that was worn by the patient and attached to the wheelchair; the
code is not valid for claims submitted to DMERC for dates of service 7/1/02 and after. The
shoulder harness device that was included in this ADMC is a wheelchair accessory that is
used to facilitate positioning for some patients who need assistance with trunk support.
Suppliers should contact the SADMERC for the correct code to use for the shoulder harness
device. The note (correct code) was included in the response for K0064 because we
sometimes see the wrong code used for flat-free inserts used with manual wheelchairs. In this
case, though, the supplier had used the correct code so the parenthetical comment was not
necessary. The K0069 was at one time a part of the ADMC response template and should
have been removed for this request, but was not. We have since revised the template so that
codes must be added, not deleted, which should hopefully prevent this problem from
occurring.
5. The Medicare manual (WCB-pg2) indicates, "a power wheelchair is covered if the patient’s
condition is such that the requirement for a power wheelchair is long term (at least 6
months)." Does this refer to the purchase only and shouldn’t short-term rental be allowed?
The following example sites an instance where the individual required 2 to 3 months use of a
power chair due to surgery. The claim was denied indicating that the need was not 6 months
or longer. This was taken to hearing with the same result.
Answer:
Dr. Hoover will discuss with the other DMERC Medical Directors the policy
provision restricting need to a minimum of 6 months to allow a shorter period of need if the
chair will be rented.
HME A-Team
1. Transmittal AB-01-137 allows DME suppliers to verify Medicare eligibility over the
telephone. Since eligibility is available over the telephone, why cannot customer service also
provide eligibility information on same/similar equipment?
Answer:
Medicare eligibility does not encompass same/similar equipment. The following is
the scope of information that may be released:
•
Medicare Part B eligibility date
•
Medicare Part B eligibility term date
•
Medicare HMO information
•
MSP information
a. Additionally, we have received information from our members that the DMERC CSRs
are also requesting the patient’s address, and or have been reluctant to provide
information when the supplier provides the required information. This has been addressed
for the individual supplier, but has training taken place to address the issue with the entire
CSR staff?
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Answer:
The CSRs are instructed to validate the following information prior to releasing
beneficiary eligibility information to suppliers:
•
The supplier name
•
The supplier number
•
The beneficiary name
•
The beneficiary date of birth
•
The beneficiary HICN
•
The beneficiary gender
These must match exactly before eligibility information can be released.
2. Several suppliers are reporting receipt of documentation audits via facsimile from the CIGNA
Medicare Benefit Integrity Unit, without any communication received by mail or phone. The
requests have been for an average of 3-4 patients with DOS in 1995 through 1997. The letter
instructs the supplier to provide the documentation within 5 or 10 days. We find these
requests unusual on two points:
a. Why are the audits being faxed, not mailed to the supplier?
Answer:
All requests for documentation are in writing
.
b. The dates of service being requested are not recent thereby requiring most suppliers to
order the files from storage making the 5 or 10-day time limit impossible to meet. Would
it be possible to set standards for the number of days to return documentation, possibly
based on DOS?
Answer:
If a provider/supplier has difficulty in meeting the time frame, they should
contact the requestor. Providers/suppliers are required to maintain documentation for
seven years and requests are not unusual.
3. Additionally a benefit integrity analyst told one of our members that Region D DMERC has
instructed them to survey or "audit" closed providers. In these instances they are to phone and
fax a closed provider. If no response to either the phone call or faxed document is received,
then an overpayment letter is generated - to which a response is not expected. This closed
provider is then sent to the Treasury department. The benefit analyst was unsure what
happens after that but believed the file to be closed; however that is not the case. The
Treasury department then generates an overpayment and interest accumulated letter and a
collection agency is retained to "go after" the supplier or the owner of that liability. Questions
concerning these audit practices follow:
a. As to the "search" for closed suppliers - it is a requirement of the NSC application
process for suppliers to disclose mergers, acquisitions, and closed practice locations -
where is the mandate to the DMERCs to audit closed suppliers?
Answer:
Closed providers/suppliers are not selected for audit based on their status
.
b. What procedures do you plan to implement to ensure that the correct contact information
is used when conducting an audit?
Answer:
Contact information is obtained from the NSC. It is the provider/supplier's
responsibility to maintain current information with the NSC.
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4. What is the supplier’s responsibility in obtaining a CMN for a non-assigned claim? Please
explain.
Answer:
Please refer to the DMERC Region D Supplier Manual in Chapter 3, page 1, under
Supplier Documentation. This information applies
to both assigned and non-assigned
claims
. It states " Before submitting a claim to the DMERC, the supplier must have on file a
dispensing order (verbal, faxed, original or electronic), the detailed written order (electronic,
faxed or original), the Certificate of Medical Necessity (CMN) (electronic, faxed or original,
if applicable), information from the treating physician concerning the patients diagnosis, and
any information required for the use of specific modifiers or attestation statements as defined
in certain DMERC local medical review policies (LMRPs).".
5. The Fall 2002 Supplier Manual update has deleted the repair policy. What will be the new
repair policy for patient owned equipment and when will it be effective?
Answer:
The Repairs local medical review policy was retired and will be reissued at a future
date. No effective date has been set.
6. Written Orders Prior to delivery - now that faxed or electronically transmitted orders and
CMNs are accepted for both billing and auditing purposes; what form does the WOPD need
to be? Original or are faxes or electronically transmitted orders prior to delivery acceptable?
Answer:
Written orders for those items that require a written order prior to delivery may take
the form of a photocopy, facsimile image, electronically maintained document or original
"pen and ink" document. The DMERC Region D Supplier Manual will be updated to reflect
the Program Memorandum from CMS outlining this change.
7. In the event that a Medicare beneficiary does not notify their supplier that they have become
Medicare eligible in a timely manner, is the supplier entitled to bill the Medicare beneficiary
privately for the dates of service they may not qualify for? For example:
A patient is on service renting oxygen equipment. The patient has private insurance as a
primary insurance company and NO test results were required to qualify for the private
insurance company to reimburse the provider. The beneficiary fails to notify the supplier
that they became Medicare eligible. The supplier is not able to obtain an ABN because
they were not notified of the Medicare eligibility date. Additionally, the supplier is not
able to obtain qualifying test results because they were not notified of the change in
benefits. Would the supplier be allowed to bill the patient privately for the full retail of
the oxygen rental until the patient is tested?
Answer:
Duplicate question. This is addressed in Respiratory section
. Please see answer
to question 14.
8. The Fall 2002 DMERC Dialogue, page five, article "ICD-9 codes will be date of service
driven" states:
Effective January 1, 2003, the annual ICD-9 updates will be date of service specific.
Providers and billing staff must bill claims using the diagnosis codes that are in effect at the
time the service is rendered.
6
If a physician prescribed an item in 1998 using an ICD-9 code that was valid at the time, but will
become invalid (deleted) as of January 1, 2003 what steps must the provider take to bill with the
appropriate ICD-9 code for any date of service on or after January 1, 2003?
a. Is the provider required to obtain a revised prescription or CMN?
Answer:
Pending CMS discussion.
b. Can the provider modify the ICD-9 code from the invalid to the valid replacement
code?
Answer:
Pending CMS discussion
.
c. Should ICD-9 codes be grand fathered on existing patients for the life of the CMN?
Answer:
No, ICD-9 codes will not be grandfathered.
Follow-up Request for Same or Similar Issue
The process that our DMERC carrier, CIGNA Medicare has advised us on "same and similar"
denials is to forward to review a signed document by the beneficiary stating they have been asked
if they have ever had the requested equipment before and answered "NO", once going to review
the claim would be paid due to the fact we asked the question but they supplied the wrong answer
and we have no other means to find the correct answer-to make this process more efficient for all
parties, could there be a modifier places on the original claim submission (like done on many
other product and processes) stating we have this document on file which then would resolve one
of the "same and similar" issues upfront?
Answer:
Doubtful that a new modifier would be created. In addition to asking the beneficiary,
suppliers also have the option of a 3-way call with the beneficiary (or the beneficiary’s
representative) and DMERC Customer Service.
Medical Supplies A-Team
9. The Fall 2002 DMERC Dialogue (pg7) and revised medical policy include specific
information required for coverage of diabetic supplies. The coverage requirements include
significant reference to the physician’s medical record. In that the policy states "physicians
are not required to fill out additional forms from suppliers or to provide additional
information to suppliers unless specifically requested of the supplier from the DMERC", we
believe suppliers will have difficulty determining if the physician's records include the
required information. Would you consider writing an educational article to physicians
regarding these requirements with a request to the Part B Carriers for inclusion in their next
bulletin? It would be helpful to clearly articulate the consequences to providers should the
physician sign a complete and valid order that does not have specific corresponding entries in
an additional separate format within the medical record.
Answer:
Several bulletin articles have already been sent to the local carriers for publication,
most dealing with documentation. Another article is being prepared to specifically address
orders. Dr. Hoover will consider a separate article dealing with diabetic supplies and
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physician documentation responsibilities
.
10. Carriers Manual Transmittal #1759 dated 7/24/02, states that DMERCs will process claims
that span two calendar years on a single claim line. Previously, providers were required to
split claims that spanned two calendar years into two claim lines. Will CIGNA be
implementing this change prior to year-end?
Answer:
No. CIGNA Medicare will be implementing the changes outlined in Transmittal
1759 (Change Request 2063) with the January release. Claims for items that require span
dates that are received by the DMERC on or after January 1, 2003 that contain a span date
extending over two years will be processed on one claim line. Pricing and deductible
calculations for these claims will be based on the "from" date.
How is new information such as documentation requirements on POVs and/or the questions
and answers between CIGNA and the DAC communicated to Customer Service Agents?
Since this change, some providers have spoken with agents that are not aware of the change
in requirements.
Answer:
Dr. Hoover addressed the CSRs in the August CSR meeting regarding the change in
POV documentation requirements. If there is a question that the DAC presents and CIGNA
deems it to be a global issue, then it will be communicated to the customer service area.
11. The Summer 2002 DMERC Dialogue includes an article on documentation requirements for
power-operated vehicles. The article states that the DMERC will focus additional
documentation requests, based on data analysis, on those claims where information indicates
that coverage criteria for a POV may not have been met. The article appears to relate
information contained in the Program Memorandum (PM) Transmittal #B-02-031 related to
POVs and power wheelchairs. Please clarify how these instructions might be applied to other
routine requests for additional information on items requiring a CMN (category 4 enteral
formulas for example). The PM states that collections of information must be approved
unless it fits within exceptions for audits and investigations. There are additional categories
or specific items, which the DMERC routinely requires documentation in addition to
information contained on the CMN. In those cases, is there also a potential conflict with the
Paperwork Reduction Act as cited in this PM?
Answer:
Dr. Hoover will look at the example cited and discuss with the appropriate
personnel at CMS regarding implications with the PRA.
Orthotics & Prosthetics A-Team
12. Two procedure codes for an ocular prosthesis appear to be out of step with the current usual
and customary fees as defined by Medicare and what the actual cost is to a Medicare patient.
Physicians in region D commonly prescribe the two codes V2623 and V2627. Ocularists
rarely can take
(Biddle & Associates attachment pp1-13)
assignment of benefits, as the fees
charged for these prostheses are usually 50% higher than what Medicare deems to be fair and
reasonable charge. The ocularists in region D commissioned a cost and benefits survey to be
handled by an outside and neutral survey company. The results of this survey were
outstanding in that the number of ocularists that can take assignment of benefits from a
patient hovered around 14%.
8
The majority of ocularists had to charge a rate that was 50% higher than the amount allowed
by Medicare. This has the appearance of a situation where Medicare is out of step with the
market in setting up the Medicare allowable fee. It is apparent that steps need to be taken to
close this gap in the allowed amount and the usual and customary charge by the majority of
ocularists in region D to not place an undue burden on the Medicare recipient who is in need
of the services by ocularists to fabricate, fit and deliver an ocular prosthesis. What
information can we provide to the DMERC to get Medicare to readjust the fee schedule to
better the reimbursement rate to relieve this burden on the Medicare recipient. The results of
this survey are non participating this is evidenced by the small amount of respondents who
indicated that they were participating providers
(Region D participating and non
participating providers).
Question:
What is your usual and customary fee for procedure #V2623 (fitting and
fabrication of a custom ocular prosthesis) versus a Medicare allowable fee?
See attachment No. 1
Answer:
CIGNA is aware that the fees for ocular prosthetics codes are, in some cases,
significantly lower than the "usual and customary" fees charged by ocularists. Until inherent
reasonableness authority is restored to the DMERCs, there is no mechanism for adjustment
of the fee schedule for these procedure codes.
13. In the past the DAC O/P A-team has asked the status of credentialing/certification for the area
of Diabetic shoes fitters. Has there been any more information, thoughts or open lines for us
to communicate our position on this issue. In regards to this same matter, there has been some
speculation through out our industry that if the current phrase "other healthcare provider"
were to be interpreted not to include the current mix of providers, there may be a potential to
retroactively ask for revenue already paid, back from the provider. Though at this point only
speculation, any comments to help educate us, and what could we provide to the DMERC to
preclude this possibility.
Answer:
The DAC O & P A-Team is welcome to send comments or thoughts through Dr.
Hoover on the issue of credentialing diabetic shoe fitters. From the perspective of Region D
medical review, the speculation that any changes in the interpretation of "other healthcare
provider" would be applied retroactively is unfounded. Unless Region D medical review is
instructed by CMS to the contrary, any changes to the current mix of providers would be
applied prospectively with adequate notice.
Previous Submitted Question
There is a continuing problem with the DMERC regarding the cleaning of an ocular prosthesis as
well as the reimbursement rates for procedure codes V2623 (custom acrylic ocular prosthesis)
and V2627 (custom sceral shell prosthesis). There is a lack of guidance from the DMERC
regarding the number of times per year that an ocular prosthesis can be cleaned and billed to
Medicare for appropriate re-imbursement. This has been an on going problem. What further
information is required that would solidify Medicare’s position on the cleaning of an ocular
prosthesis?
Answer:
There is guidance on the polishing and resurfacing of an ocular prosthesis. The
allowance is once per year. Based on previous discussions, the DMERC Medical Directors will
9
be revising the policy to allow this service twice per year. The policy revision is forthcoming,
probably in the spring 2003.
Respiratory A-Team
14. In the event that a Medicare beneficiary does not notify their supplier that they have become
Medicare eligible in a timely manner, is the supplier entitled to bill the Medicare beneficiary
privately for the dates of service they may not qualify for?
Example:
A patient is on service renting oxygen equipment. The patient has private
insurance as primary coverage and no qualifying Saturation's or ABG’s were required for
payment. The beneficiary fails to notify the supplier that they became effective with
Medicare. The supplier is not able to obtain an ABN because they were not notified of the
Medicare effective date. Additionally, the supplier is not able to obtain qualifying test results
because they were not notified of the change in benefits.
Answer:
It is the responsibility of the supplier to be aware of any changes in eligibility for
their customers/beneficiaries. Please refer to the DMERC Region D Supplier Manual,
Chapter 9, OXY, page 5 under Initial CMN is Required. It states, "With the first claim to the
DMERC for home oxygen (even if the patient was on oxygen prior to Medicare eligibility or
oxygen was initially covered by a Medicare HMO)."
When sending in the CMN the initial date would be the date of Medicare eligibility and the
test date on the CMN would be when a test was performed. Since Medicare coverage cannot
be allowed without qualifying test results the dates of service prior to the test date on the
CMN will be denied The denial message should be PRB17, which says "Payment adjusted
because this service was not prescribed by a physician, not prescribed prior to delivery, the
prescription is incomplete, or the prescription is not current."
15. Suppliers are continually receiving requests to provide Bi-Level (RAD) to patients with a
diagnosis of Morbid Obesity Hypoventilation Syndrome in which COPD is not a factor.
Morbid Obesity could fall under the Restrictive Thoracic Disease if we agree that obesity
contributes to a restrictive type lung disease causing eventual increased PaCo2 greater than
45 mmhg.
Example: Patient diagnosed with Obesity Hypoventilation Syndrome weighing 450 Lbs.,
Oxygen Saturation's in the 70's and a PaCo2 greater than 45 mmhg.
Question:
Is there any hope for coverage from Medicare for this patient?
Answer:
The issue of obesity and qualification for RAD was addressed in the Fall 2002
DMERC Dialogue (page 4).
Respiratory Assist Devices – Disease Classification
In the Local Medical Review Policy on Respiratory Assist Devices, the covered conditions
are divided into four categories. The first category is Restrictive Thoracic Disorders. This
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category includes patients with either neuromuscular disorders (e.g., ALS) or severe chest
wall deformities. It does not include patients with various interstitial lung diseases that often
lead to pulmonary fibrosis and are sometime referred to as restrictive lung diseases. RADs
are not part of the treatment for these conditions. Similarly, obesity is not included in the
Restrictive Thoracic Disorders category. Patients with severe obesity may qualify under
other categories such as the Obstructive or Central Sleep Apnea categories if a
polysomnogram and other tests, as detailed in the LMRP, indicate this is the appropriate
diagnosis.
Suppliers should refer to the LMRP on Respiratory Assist Devices for further details
concerning coverage, coding and documentation requirements for these devices.
16. If a patient has a CPAP machine that was purchased by a commercial insurance, do we still
need to have proof that they are still using the equipment before we can bill with the KX
modifier for supplies and repairs?
Answer:
Yes.
Education /Communication A-Team
17. CMS has a Do Not Forward Initiative (DNF Initiative) in effect that requires the DMERCs
and the NSC to deactivate a company’s provider number if a single piece of mail, which is
posted, "Do Not Forward", is returned to the DMERC. Would you provide us with the steps
the DMERC takes when a DNF action is initiated to a Provider? Who in the DMERC is
responsible for the DNF Initiative processes? Does the DMERC know how many DNF
actions were caused by a mistake in mail delivery by the U.S. Postal Service?
Answer:
The National Supplier Clearinghouse (NSC) is responsible for updating
addresses for all four DMERCs. CIGNA Medicare receives a daily update from the NSC.
This means that if an address has been updated between the time that a check or a
remittance is mailed and the mail is returned to the DMERC, the returned mail is
remailed to the new address. If the address has not changed, the supplier is flagged and
all subsequent payments are stopped until the address has been updated. The DMERC
does not do any follow-up investigation on the address.
The area with primary responsibility for the Do Not Forward process at CIGNA
Medicare is the Banking Operations team. Since the NSC maintains records for all four
DMERCs our customer service representatives have been trained to refer calls to them if
an address needs to be corrected.
There is really no efficient way of tracking if mail is returned because of a postal error.
All of those calls are referred to the Banking Operations Team since outside of the NSC
we have responsibility for setting or removing flags.
18. When an item reaches the 15
th
month cap and then a free upgrade is provided (e.g. K0001
wheelchair is upgraded to a K0003 but there is no break in service or change in patient’s
condition) how do you bill? Would you bill the K0001 or the K0003? Would you use the MS
modifier and the upgrade modifier?
11
Answer:
. Suppliers should bill the claim with K0001MSGL. In addition, the following
information must be sent in the narrative for electronic claims or in field 19 of a paper claim:
•
Make and model of upgraded item
•
Why the item is an upgrade
When billing free upgrades, remember to only charge for the item ordered
19. Can a provider, who gathers ICD-9 and/or diagnosis information at intake, reiterate this to the
physician and place it on the Detailed Written Order?
Answer:
Information provided by the physician to the supplier in the verbal order may be
restated and confirmed in the written order.
20. Is a supplier required to list the applicable HME billed items on the lifetime assignment of
benefits form? Is the provider also required to list the HIC#? If so, please provide the source
for these requirements.
Answer:
If you are referring to the one-time authorization, please reference DMERC Region
D Supplier Manual in Chapter 6, page 12 for our suggested form. Before a supplier can use
signature on file (SOF) they need to follow these instructions. Non-assigned DME rentals
require a signature be obtained each month.
21. Request for clarification on a 3-month diabetic supply patient. If the patient gets their refill of
supplies a few days early, do you bill it when they received the goods as the DMERC
suggests? Are you risking a denial since supplies were already billed for that period? We
have heard that some DMERCs are allowing a 10-day grace period. What is the standard in
Region D?
Answer:
For claims billed for blood glucose monitor supplies that are refilled early, the date
of service on the claim must be the same as the date the supplies were provided to the
beneficiary (e.g., beneficiary goes to drug store and buys supplies), or the date sent if the
supplies are mailed or shipped to the beneficiary; this is the same as for supplies that are not
refilled early. There is minimal risk that supplies will be denied due to early billing, since the
Region D DMERC takes the possibility of early delivery into consideration when reviewing
claims; the degree of risk would primarily depend upon the quantity billed and how many
days early they are billed. Region D does not use a standard grace period, but takes into
consideration the beneficiary's historical billing pattern, the number of days by which the
dates of service precede the usual billing date, and additional information provided by the
supplier. An explanation included with the claim in situations where a quantity that is greater
than usual is provided, and/or supplies are provided more than a few days early, should
mitigate any risk associated with this situation.
EDI/EMC A-Team
22. The HA0 record in the NSF format is 280 characters long. The corresponding NTE segments
in the 837P HIPAA claim transaction are 80 characters long. What should we do when we
have more than 80 characters of narrative information to send?
Answer:
The ANSI X12N837 v.4010 transaction allows for 80 characters per claim in
addition to 80 characters per line. We recommend including as much general claim
12
information at the claim level and any specific line information at each line. We have also
been encouraging suppliers to abbreviate. Refer to the Winter 98 edition of the EDI Edge for
some common wheelchair abbreviations. Please refer to your DMERC Region D Supplier
Manual and Region D DMERC Dialogues for specific policy information required in order to
submit your claim.
23. We need detailed information on the HIPAA reports package and have been told that it’s in
the EDI Manual. How can we get a copy of the new EDI Manual for HIPAA transactions?
Can we get it before starting to send electronic transactions?
Answer:
The manual will be sent once the EDI Department receives your request to begin
testing. You can continue to submit NSF production claims while you test the ANSI format.
Effective November 1, 2002, an option will be added to the DMERC EDI Customer Profile
for electronic billers to request migration to the ANSI format. This form will be available on
our Web site. Another option to request migration is to contact our EDI department at
866.224.3094 (option 4). However, we encourage suppliers to utilize the customer profile.
This form can be either faxed or mailed to the EDI department.
24. Can we do more robust HIPAA claim testing than the required 10 test claims?
Answer:
To make it easier to identify and correct any errors, we recommend you start with
10 claims. Further, we recommend you create 10 claims that encompass all types of claims
you would submit (ie, CMNs, MSP, Medigap, Legal Representative, narrative). Once you
complete testing and are activated, you can continue to submit claims to the test region.
25. For CMN 0102B, please provide the specific FRM01 value for each of the following:
o
Ulcer #1 – Stage
o
Ulcer #1 – Max. Length
o
Ulcer #1 – Max. Width
o
Ulcer #2 – Stage
o
Ulcer #2 – Max. Length
o
Ulcer #2 – Max. Width
o
Ulcer #3 – Stage
o
Ulcer #3– Max. Length
o
Ulcer #3– Max. Width
Answer:
o
Ulcer #1 – Stage 21A
o
Ulcer #1 – Max. Length 21D
o
Ulcer #1 – Max. Width 21G
o
Ulcer #2 – Stage 21B
o
Ulcer #2 – Max. Length 21E
o
Ulcer #2 – Max. Width 21H
o
Ulcer #3 – Stage 21C
o
Ulcer #3– Max. Length 21F
o