FAQ for California Wildfires - JA DME

Q1. Does Medicare pay for the replacement of DME items lost, destroyed, or irreparably damaged due to a disaster?
A1. Medicare will cover the replacement of equipment or items that are lost, destroyed, irreparably damaged, or rendered unusable due to an emergency or disaster. This includes various supplies, drugs, oxygen, capped rentals, customized items, and other prosthetic and orthotic devices. However, Medicare does not cover the replacement of items that require frequent and substantial servicing or rented IRP items.

Suppliers need to include the "RA" modifier and a narrative on the claim explaining why the equipment must be replaced. They must also maintain documentation indicating that the DMEPOS was lost, destroyed, or otherwise rendered unusable due to a disaster.

If the item is affected by a formal waiver, the "CR" modifier is mandatory on claims for items and services for which Medicare payment is conditioned on the presence of a formal waiver, such as those granted under Section 1135 or Section 1812(f) of the Act. Suppliers should annotate the claim with both the "RA" and "CR" modifiers and include all other applicable modifiers.

Note: When replacing equipment or items, a new capped rental will start.

Q2. Are refill requirements applicable during a natural disaster? Can we dispense supplies early?
A2. Under current Medicare refill requirements, suppliers can deliver supplies such as diabetic testing materials, surgical dressings, and urological items no more than 10 days before the existing supplies are exhausted. Providing these items earlier than 10 days before the supply runs out, or if the supply is not nearing exhaustion, is not allowed under the current guidelines.

Q3. Will my emergency or disaster related replacement equipment and/or supplies be covered for items initially denied by Medicare?
A3. If an item was initially denied by Medicare, the replacement of that item would generally not be covered unless the denial was successfully appealed. Medicare coverage decisions are based on whether the item is deemed medically necessary and meets specific criteria. If the original item was denied because it did not meet these criteria, the replacement would likely face the same issue.

However, suppliers have the right to appeal Medicare's decision if you believe the denial was incorrect. Many appeals are successful, with a significant percentage resulting in coverage for the beneficiary. If the appeal is successful and Medicare approves the original item, then the replacement due to loss, destruction, or irreparable damage could be covered.

Q4. Is documentation still required during a disaster/emergency?
A4. Yes. Documentation requirements still apply during a disaster or emergency. However, DME Medicare Administrative Contractors (MACs) to have the flexibility to waive replacements requirements such that the face-to-face requirement, a new physician's order, and new medical necessity documentation are not required.

For example, Section 1135 waiver is invoked, certain Medicare requirements can be waived or modified to ensure that beneficiaries continue to receive care CMS Emergency download PDF. This can include adjustments to documentation requirements, but suppliers must still maintain records indicating that the equipment or supplies were lost, destroyed, or rendered unusable due to the disaster.

Use of the "CR" modifier is mandatory on claims for items and services for which Medicare payment is conditioned on the presence of a "formal waiver" including, but not limited to, waivers granted under either Section 1135 or Section 1812(f) of the Act. The "RA" modifier is also required on the claim for a replacement base item.

If suppliers are aware that the item is a replacement, they should annotate the claim with the "RA" and "CR" modifiers and append all other applicable modifiers.

Suppliers must include a narrative on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged, or otherwise rendered unusable as a result of a natural disaster.

It's important for suppliers to stay informed about any emergency declarations and specific waivers that may impact documentation requirements during such events.

Q5. Do I have to apply for a 1135 waiver for this disaster?
A5. No, a blanket waiver has been issued, suppliers do not have to apply for an individual waiver.

Q6. How do beneficiaries locate a DMEPOS supplier if they have been displaced and do not have access to their current equipment or supplies?
A6. If beneficiaries have been displaced and do not have access to their current Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), they can locate a new supplier by following these steps:

• Contact Medicare: Beneficiaries can call 1-800-MEDICARE (1-800-633-4227) for assistance. TTY users can call 1-877-486-2048. Customer service representatives can help locate a nearby supplier.
• Use the Medicare Supplier Directory: Beneficiaries can access the Medicare Supplier Directory online to find suppliers by geography, proximity, and name.
• Check with Local Health Services: Local health departments or emergency services may also provide information on available DMEPOS suppliers in the area.
• Reach Out to National Provider Enrollment (NPE): Beneficiaries can contact NPE West for assistance. NPE West covers states like Alaska, California, and Texas

Q7. Do we have to use a Medicare supplier, or can anyone dispense DMEPOS items?
A7. Replacement DMEPOS items must be provided by a Medicare-enrolled supplier.

Q8. How can displaced beneficiaries who are unable to reach their regular providers obtain supplies, orthotics, prosthetics, and durable medical equipment?
A8. To find out which suppliers service their current area, beneficiaries should call 1-800-MEDICARE. As an alternative, they can get a list of suppliers by name, location, and proximity.

This information is a summary of important disaster related information for Noridian Healthcare Solutions Jurisdiction A DME MAC. Additional information including waiver information, billing guidelines, frequently asked questions, and educational sessions can be accessed on the Emergencies and Disasters webpage.

Q9. When should the CR modifier be used?
A9. The CR modifier is to be used for catastrophe/disasters. It is mandatory for applicable HCPCS codes on any claim for which Medicare Part B payment is conditioned directly or indirectly on presence of a "formal waiver"

Add a narrative in the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format or field 390-BM of the National Council for Prescription Drug Program (NCPDP) format. These abbreviations may also be used in Item 19 of the CMS-1500 claim form. For example:

• CA Wildfires
• Lost-Wildfire
• Destroyed-Wildfire