Article Detail - JA DME

Advance Determination of Medicare Coverage (ADMC) is a voluntary program. Beneficiaries and suppliers are not required to submit ADMC requests in order to submit claims. Additionally, DME MACs may not require an ADMC request as a prerequisite for claim submission.

Several DME items are customized and are quite costly to purchase; therefore, beneficiaries and suppliers can request an ADMC. It is important to note that an ADMC decision is not an initial determination as defined in 42 CFR 405.920 and 405.924, because no request for payment is being made. As such, an ADMC decision cannot be appealed.

An ADMC is a request by the supplier or beneficiary to determine if an item may be covered before the item is delivered. HCPCS eligible for ADMC determination are:

Manual Wheelchairs

• E1161, E1231, E1232, E1233, E1234, K0005, K0008, and K0009

Power Wheelchairs

• K0890, K0891, and K0013

ADMC Request

The ADMC request is sent with a coversheet and is faxed or mailed to Noridian Healthcare Solutions. The ADMC request must include the documentation listed on the coversheet. Once a request is received, the DME MAC shall determine if there is sufficient medical documentation to support whether or not the item is reasonable and necessary. The DME MAC shall render a determination within 30 calendar days in writing with their decision, whether affirmative or negative.

Requests received for appropriate items without documentation to support coverage will be denied as not meeting the Medicare established medical necessity requirements.

ADMC MR Decisions

An approved ADMC decision provides the supplier and the beneficiary with assurance that the beneficiary will meet the medical necessity requirements Medicare has established for the item. This assurance is based on the information submitted with the request.

An affirmative ADMC decision is valid for a period of six months from the date the decision is rendered. The date the item is provided to the beneficiary cannot be more than six months after the date the ADMC decision was rendered.

A negative ADMC decision indicates to the supplier and the beneficiary that the beneficiary does not meet the medical necessity requirements Medicare has established for the item. Requests may be resubmitted once during a six-month period for a negative ADMC decision only if additional medical documentation is supplied.

The DME MACs provide their decision to the requestor in writing, whether affirmative or negative. Currently, there is no way to view an ADMC status on the Noridian Medicare Portal. ADMC decision information can be found on the Interactive Voice Response (IVR) system by selecting the Prior Authorization function and speaking a verbal response of prior or a touch tone response of 1. The information that can be obtained is:

• Receipt date, status (pending, affirmed, denied), and tracking number

The IVR guide can be found on our website under Contact > Interactive Voice Response (IVR) - Self-Service Technology.

Questions

If suppliers have additional questions, call the Pre-Claim Hotline regarding the ADMC process or any negative or affirmative decisions.

Acceptable use of the hotline includes; questions a supplier may have during the preparation of an ADMC submission, questions on a decision that was received, or information on coverage criteria.

When calling the hotline number, the caller will be directed to a voicemail. He or she must provide the information below.

• Beneficiary name
• Supplier name
• Phone number
• Hours of availability and time zone
• Beneficiary Medicare number or Medicare Beneficiary Identifier (MBI), if applicable
• A brief description of the question or issue

A clinical reviewer will return each voicemail within two business days.