Same or Similar: How to Avoid Denials - JA DME

Numerous DMEPOS claims deny because the equipment/item billed is the “same as” or “similar to” the equipment/item already in a beneficiary’s possession and is within its Reasonable Useful Lifetime (RUL). When such a claim denies, suppliers should submit a Redetermination request and include all applicable documentation, which may consist of details supporting lost or stolen items, or irreparable damage to item or medical records from the prescribing physician/practitioner to substantiate the need for a different item (change in medical condition), when appropriate.

Prior to providing an item, and to gain the necessary information required to determine whether an Advance Beneficiary Notice of Noncoverage (ABN) should be obtained or not, it is best to verify same or similar details within the Same or Similar functionality in the Noridian Medicare Portal (NMP) or via the Interactive Voice Response (IVR).

The beneficiary or caregiver is another important source in determining whether same or similar items have previously been provided. Suppliers should ask the beneficiary or caregiver if they have received similar items in the past.

It is important to note that the IVR and NMP will confirm that a beneficiary either has or not had a same or similar item with Jurisdiction A. It is the supplier’s responsibility to check other jurisdictions for same or similar, including Jurisdiction D, if there is reason to believe that the beneficiary may have obtained a same or similar item within a different jurisdiction. The claims in the NMP are specific to each Jurisdiction so each Jurisdiction, JA and JD, may need to be verified along with other jurisdiction’s portals for same or similar.

To access information about same or similar denials, ABN documentation, RUL clarification, billing reminders for RUL and duplicate Items, and a list of same or similar items, suppliers may also visit the Same or Similar Chart webpage.

Prior to replacing an item, and to gain the necessary information required for determining whether same or similar is affected, these questions should be considered:

• Has there been a change in the beneficiary's medical condition that supports the need for a same or similar type of item?
• Has the original item been lost, stolen, or irreparably damaged?
• Answering these questions will help determine whether an Advance Beneficiary Notice of Noncoverage (ABN) should be obtained
• Has the beneficiary had a same or similar item?
• If he/she has not had a same or similar item, bill claim without obtaining an ABN (no ABN necessary)
• If he/she has had a same or similar item, determine if item has reached its RUL
• If RUL reached, bill claim without ABN (no ABN necessary)
• If item has not reached RUL, obtain an ABN and bill claim with applicable GA modifier