Customer Service and Claim Submission - JA DME

View FAQs based upon the top 10 telephone, top 10 written inquiries, and claim submission related inquiries.

• Customer Service
• Claim Submission

Customer Service

Q1. Can the Noridian Medicare Portal (NMP) check Same or Similar HCPCS ranges?
A1. Yes. Suppliers can obtain ranges for all HCPCS codes via the NMP. See Option 2 of the Same and Similar category.

Q2. What are some reasons why my claim denied as not medically necessary?
A2. There are many various reasons why a claim can deny as not medically necessary. The two most common reasons are denied audits and diagnosis codes. If a claim was audited and the records sent didn't support medical necessity, a redetermination needs to be sent with all pertinent documentation. Suppliers will want to review the Local Coverage Determination (LCD) for specifics that might be required. Some LCDs contain specific diagnoses that codes must appear on the claim to support medical necessity.

Q3. A couple of HCPCS codes on a claim denied for frequency, but it wasn't billed above the LCD guidelines. How can one supplier tell if another one was paid?
A3. Noridian strongly suggests checking Same and Similar on the NMP or Interactive Voice Response (IVR) prior to submitting a claim.

Q4. If the IVR states Medicare is secondary to a No Fault, Liability, or Worker's Comp insurance, how should a supplier find out if they should bill Medicare or the other insurance?
A4. NMP does release the diagnosis codes listed on the patient's diagnosis driven file; however, these are not all inclusive. They are part of a family of diagnosis codes and can be used as a guideline. If the file in question is old, the patient must contact the Benefits Coordination and Recovery Center (BCRC) to close it out.

Q5. Oxygen count was lost on a patient. How can a supplier verify this information?
A5. There are two ways suppliers can verify this information.

1. Call IVR and use Option 1 (Provider Contact Center), Option 3 (Same and Similar)
2. Access NMP and Option 1 under Same and Similar

Q6. How can a supplier tell if the code billed requires the KX modifier?
A6. All KX modifier information can be found in the LCD associated with the item given. Prior to billing so claims aren't denied, check the modifier section of the LCD.

Q7. Can a supplier do an ADMC on a lower limb prosthetic?
A7. No. Currently ADMCs are only available on certain customized wheelchairs.

Q8. How does a supplier get a DIF loaded?
A8. If a DIF isn't loaded with the initial claim submission, it must be sent in as a redetermination with all pertinent medical documentation.

Q9. Can a CSR help with general claim status?
A9. No, per CMS direction, all general claim status inquiries must go through either the IVR or NMP. The Supplier Contact Center Customer Service Representatives (CSRs) may assist suppliers with questions regarding a claim denial.

Q10. What should a supplier do if their claim gets denied for the ordering physician not being enrolled in Provider Enrollment, Chain, and Ownership System (PECOS)?
A10. Contact that referring physician and have them check their PECOS file or call their Provider Enrollment department to find out what the issue is. Once this is updated, claims can either be resubmitted or reopened. As a reminder, make sure to enter the referring physician's information in the following format. First name, last name, no middle initial, and no credentials.

Q11. How long does it take to receive a response from a written inquiry or email?
A11. Written Correspondence has 45 business days to respond to written inquiries, including emails. Inquiries will be answered in the order they are received. Duplicate inquiries may increase response time.

Q12. How can a supplier reopen multiple claims?
A12. If a supplier has multiple claims to reopen, there are two different options to accomplish this without having to call for each claim individually. The first option is to submit a special project. To see if claims qualify for a special project request and for information on how to submit these requests, read the section titled "Special Project Requests" located on the Reopening webpage.

The NMP also has a self-serve option for reopening claims. If a supplier does not have a NMP account, we encourage registration. See the Noridian Medicare Portal webpage for registration and function details.

Q13. Does Durable Medical Equipment (DME) cover influenza vaccines?
A13. According to the 2020 Jurisdiction List , influenza vaccines should be billed to Part B.

Q14. Can a DME supplier Opt-Out?
A14. DME does not offer the option for suppliers to "Opt-Out." This is an option only given to Medicare Part B practitioners; however, Medicare DME suppliers and providers can elect to not be a part of the Medicare DME program. The National Provider Enrollment (NPE) handles all aspects of enrollment in Medicare DME so suppliers should contact them regarding "opting out" and reenrollment in the Medicare DME program. Contact NPE at 1-866-520-5193. Note: DME suppliers who are no longer going to be enrolled in Medicare, can bill DME claims when the date of service falls before the term date for their enrollment.

Q15. A beneficiary wants to file a complaint on another supplier, how can he/she do that?
A15. Beneficiaries should contact 1-800-MEDICARE regarding suppliers who are not answering the phone or servicing equipment. If a beneficiary wishes to file a complaint regarding customer service, as well, they should be advised to contact their State Health Insurance Assistance Program (SHIP). Details on how to contact your SHIP to file a complaint can be found at https://www.medicare.gov/claims-appeals/file-a-complaint-grievance/complaints-about-durable-medical-equipment-dme.

Q16. A patient with private insurance gets set up on CPAP/BiPAP therapy. Three months into the rental the patient becomes eligible for Medicare. Is the patient required to meet the trial period compliance?
A16. According to the LCD for Positive Airway Pressure (PAP) devices, beneficiaries who receive a PAP device prior to enrollment in fee for service (FFS) Medicare that are seeking Medicare coverage or either rental of the device, replacement PAP device, and/or accessories, must meet the following requirements: There must be documentation that the beneficiary had a sleep test prior to FFS enrollment that meets the Medicare AHI/RDI coverage criteria in effect at the time the beneficiary seeks coverage; and following enrollment in FFS Medicare, the beneficiary must have a face-to-face evaluation by their treating practitioner who documents in the medical record that the beneficiary has a diagnosis of obstructive sleep apnea; and, the beneficiary continues to use the PAP device.

Q17. If a doctor is out on leave, is it acceptable for another doctor from the practice to finish the paperwork for a Face-to-Face completion?
A17. A different physician can complete the face to face. Suppliers should have all information and medical record documentation reviewed and signed by the physician. This will show that they concur with the information contained. See Chapter 3 of the Supplier Manual.

Q18. Do Health Maintenance Organizations (HMOs) follow the same criteria as Medicare?
A18: Medicare Health Maintenance Organizations (HMOs) are elective insurance plans that allow a beneficiary to select a private insurance company to administer their Medicare benefits instead of government contractors, such as Noridian Healthcare Solutions. These plans are required to cover all the same services as traditional fee-for-service Medicare, and may provide additional benefits, but do not necessarily have the same coverage criteria, coding, or fee schedule.

Q19. Does Medicaid follow Medicare guidelines for quantity limits?
A19. Noridian is unable to advise suppliers on how another insurance processes claims, suppliers must reach out to their states Medicaid office.

Medicare quantity limits are usually published in the corresponding LCD or Policy Article. Some codes may also have a Medicare Unlikely Edit (MUE). Some of these MUEs have been published by CMS. If a value has not been published, it means the quantity limit is confidential, and is for CMS and the Contractor's use only.

Q20. Is there a way to look up the new IDs using just the patients name and date of birth?
A20. The Medicare Beneficiary Identifier (MBI) Look-Up Tool is now available in NMP. This tool is an option for providers/suppliers to use if they are not able to obtain the MBI number from the patient. The new NMP feature will only return the MBI if the patient's new Medicare card has been mailed. The new cards are being mailed in phases. See the geographic location strategy. See the Medicare Beneficiary Identifier (MBI) Lookup Tool webpage of the NMP User Manual.

Q21. A supplier has received an increase in CO-4 denials (The procedure code is inconsistent with the modifier used, or a require modifier is missing. Invalid combination of HCPCS modifiers). How can a supplier fix these?
A21.There are several possible causes for a CO-4 denial. Use the information below to assist in determining the issue and submit a corrected claim. See Chapter 5 of the Supplier Manual for more information on payment categories, their related modifiers, rental/purchase option, and instructions on how to bill for an upgrade.

• Review the required modifiers for the payment category of the item(s) being billed
• If billing for capped rental items with initial dates prior to 01/01/06, or enteral/parenteral pumps, check to see if the purchase option modifier is required. Payment cannot be made past the 11th rental month without indicating whether the beneficiary has decided to continue to rent or purchase the equipment
• If billing for an upgrade, it is possible the modifiers were billed incorrectly

Determine if the equipment billed is missing a required modifier that indicates if coverage criteria have been met. See the appropriate LCD and/or Policy Article to determine if the KX, GA, GZ, or GY modifier is required. If the modifier is required and not present on the claim, it may deny CO-4. Add the appropriate modifier and resubmit as a new claim.

Claim Submission

Q1. How do I send claims that have no ordering physician?
A1. For claims with no ordering physician and an EY modifier (no physician or other licensed health care provider order for this item of service) is used, enter the rendering supplier's name and NPI as the ordering.

• The electronic claims format will only allow a person's name to be submitted for the ordering provider. If a supplier needs to submit their own name in an electronic claim in accordance with the general instructions for the EY modifier, and the name of the supplier is a business name instead of the name of a person, the CMS advises entering an "X" in both the first and last name fields for the ordering provider. This is in the NM103 and NM104 elements in Loop 2420E.
• If the supplier has obtained a physician's order for some, but not all, of the items provided to a particular beneficiary, the supplier must submit a separate claim for the items dispensed without a physician's order.
• Claims submitted with an EY modifier on one charge line but not on all charge lines will be rejected by CEDI.

Q2. Can I send my P.O. Box for my billing provider's address?
A2. No. The address in the Billing Provider 2010AA loop must be the physical street address and cannot be a P.O. Box.