Providing a Brace to a Beneficiary When the Beneficiary’s Medicare Order History Indicates an Item Is the Same or Similar to the Item Being Billed

Providing a Brace to a Beneficiary When the Beneficiary’s Medicare Order History Indicates an Item is the Same or Similar to the Item Being Billed

The Noridian Same or Similar Chart is not just a tool but an entire webpage of guidance. This webpage contains information on:

  • Replacement rules – what if the Reasonable Useful Lifetime (RUL) isn’t specified in the policy?
    • RUL clarification - What’s the difference between irreparable damage and irreparable wear?
  • Is the item considered same or similar?
    • What questions should I consider or ask?
    • How can I verify the information I get from the beneficiary or caregiver?
  • How can I avoid same/similar denials?
    • Did you check with all DME jurisdictions for a same/similar item?
      • The beneficiary may have been traveling or snow birding when brace was received
  • Can I use an Advance Beneficiary Notice of Noncoverage (ABN) with a same or similar item?
  • Which braces are considered the same or similar?

If a claim is denied due to same or similar claims previously paid, suppliers should submit a redetermination. Supporting documentation would need to be included with the redetermination request. Noridian encourages redeterminations/appeals be submitted using the Noridian Medicare Portal.

Examples of applicable documentation to include can be found in the Standard Written Order including:

  • Signed pick-up and delivery tickets, if applicable
  • Copy of medical record to substantiate change in medical condition
  • If item was lost, stolen, or irreparably damaged (in a specific incident) submit applicable documentation
    • I.e., beneficiary statement, police report, fire report, insurance claim information
  • Copy of ABN, if obtained

 

Last Updated Dec 28 , 2022