Article Detail - JA DME

Immunosuppressive drugs are essential for beneficiaries who have undergone organ transplants. Ensuring the beneficiary is receiving and utilizing medically necessary medications is crucial.

Key refill requirements:

• Prospective Billing: For Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) provided on a recurring basis, billing must be based on prospective, not retrospective use.
• Beneficiary Contact: Suppliers must contact the beneficiary or their designee prior to dispensing a refill. This contact must occur no sooner than 30 calendar days before the delivery or shipping date. This contact must include a documented affirmative response from the beneficiary confirming the need for a refill.
• Documentation: For items delivered to the beneficiary, documentation of a request for refill must be either a written document received from the beneficiary or a contemporaneous written record of a phone conversation/contact between the supplier and beneficiary.
• Quantity Limits: Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers are expected to stay attuned to changed or atypical utilization patterns and verify with the ordering practitioners that any changes are warranted.
• Delivery: The supplier must deliver the DMEPOS product no sooner than 10 calendar days before the end of usage for the current product.

Refer to Local Coverage Determination (LCD) L33824 and Policy Article A52474 for details.