Claims Selected for CERT Review Following Affirmed PAR - JA DME

Claims with an affirmed Prior Authorization Request (PAR) on file have the potential to be reviewed, and subsequently denied, by other entities such as the Comprehensive Error Rate Testing (CERT) program, Unified Program Integrity Contractor (UPIC), or other reviewing bodies.

The PAR programs for power mobility device (PMD), pressure reducing support surfaces (PRSS), Lower Limb Prosthetics (LLP), and Orthotics allows suppliers to submit documentation to the contractors to determine if policy and medical necessity requirements have been met prior to providing the PMD to the beneficiary.

It is important for suppliers to note that an affirmed PAR does not exclude the subsequent claims for the above-mentioned PAR program items from a CERT review in the future.

The CERT Review Contractor could potentially request the documentation that supports the payment of the items, even with an affirmed PAR on file. When this occurs, the supplier is expected to respond by providing the requested documentation supporting the items billed. Sending the affirmed PAR decision letter alone is not sufficient for CERT review.

If selected for CERT review following a PAR affirmation, Noridian encourages suppliers to send in all the documentation that was submitted with the affirmed PAR in addition to the home assessment and proof of delivery (POD). The home assessment for PMD and POD for all above items are not requirements for PAR reviews. However, they are required for a complete claim review.

Noridian also reminds suppliers to include the correct ordering practitioner's National Provider Identifier (NPI) on the claim when billing. The NPI billed on the claim should be that of the provider who completed the Standard Written Order prior to delivery (WOPD) for a PMD or the Standard Written Order (SWO) for PRSS, LLP and Orthotics.