Article Detail - JA DME
Checking for Same or Similar in the Noridian Medicare Portal (NMP) to Avoid Denials
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) claims often deny when the billed equipment or item is considered the "same as" or "similar to" what the beneficiary already possesses, and it falls within its Reasonable Useful Lifetime (RUL). Suppliers encountering such denials can take specific steps to address them effectively.
Addressing Denials: In cases where a DMEPOS claim is denied due to equipment/item similarity, suppliers should proceed with a redetermination request. This submission must include comprehensive documentation, such as evidence of lost or stolen items if applicable, or medical records from the prescribing physician/practitioner indicating a change in need. Such documentation should support the necessity for a different item, especially when a change in the beneficiary's medical condition justifies it.
Key Considerations Before Replacement: Before proceeding with an equipment/item replacement, it's crucial to consider the following questions:
- Change in Medical Condition: Has the beneficiary's medical condition changed to support the need for an item that is the "same as" or "similar to" the existing one?
- Loss, Theft, or Irreparable Damage: Has the original item been lost, stolen, or suffered irreparable damage? Answering these questions helps determine whether obtaining an Advance Beneficiary Notice of Noncoverage (ABN) is necessary.
- History of Same or Similar Items: Has the beneficiary previously received a "same as" or "similar" item? Suppliers should verify these details using the Same or Similar functionality in the Noridian Medicare Portal (NMP) or the Interactive Voice Response (IVR) system.
Answering these questions helps determine whether obtaining an Advance Beneficiary Notice of Noncoverage (ABN) is necessary.
Appropriate Action Steps: Based on the responses to the above questions, suppliers should take the following actions:
- If no previous history of a "same as" or "similar" item exists, suppliers can bill the claim without obtaining an ABN (Advance Beneficiary Notice of Noncoverage).
- If a history of a "same as" or "similar" item exists, suppliers should determine if the item has reached its RUL. If the RUL has been reached, the claim can be billed without an ABN.
- If the item has not reached its RUL, suppliers should obtain an ABN and proceed with billing the claim while applying the appropriate modifier.
Effectively utilizing the Same or Similar functionality in the Noridian Medicare Portal (NMP) and adhering to the outlined steps can help suppliers avoid denials and ensure proper billing practices for DMEPOS claims. By proactively addressing the criteria for replacements and ABN requirements, suppliers contribute to smoother claim processes and improved beneficiary care.
Resources: Suppliers can access further guidance and instructions for managing ABN requirements and the Same or Similar functionality through the provided links:
