Advance Determination of Medicare Coverage (ADMC) - JA DME

This is a voluntary program. Beneficiaries and suppliers are not required to submit ADMC requests, in order to submit claims. Additionally, DME MACs may not require an ADMC request as a prerequisite for submitting a claim.

• What is ADMC?
• Eligible HCPCS
• ADMC Request
• ADMC Process
• ADMC MR Decisions
• Questions

What is ADMC?

A request by the supplier or beneficiary to determine in advance of delivery of an item whether payment for the item may not be made because the item is not covered when:

• The item is a customized item,
• The beneficiary to whom the item is to be furnished, or the supplier, requests that such advance determination be made, and
• The item is not an inexpensive item as specified by the Secretary.

Several DME items are customized and are quite costly to purchase, therefore beneficiaries and suppliers can request an Advance Determination of Medicare Coverage (ADMC). It is important to note that ADMCs are not initial determinations as defined at 42 CFR 405.920 and 405.924, because no request for payment is being made. As such, an ADMC cannot be appealed.

Eligible HCPCS

Manual Wheelchairs

• Ultra-lightweight: K0005
• Tilt in Space: E1161, E1231, E1232, E1233 and E1234
• Custom: K0008
• Other: K0009

Power Wheelchairs

• Group 5 Single Power Option or Multiple Power Options
  • K0890 and K0891
• Custom: K0013

ADMC Request

• The ADMC request is sent with a coversheet and faxed or mailed to Noridian Healthcare Solutions with the documentation listed on the coversheet. Once a request is received, the DME MAC shall determine if there is sufficient medical documentation that supports whether the item is reasonable and necessary. The DME MAC shall render an advance determination of Medicare coverage within 30 calendar days in writing with their decision, be it affirmative or negative.
• Requests for appropriate items received without documentation to support coverage will be denied as not meeting the medical necessity requirements Medicare has established for the item.

ADMC Process

Once a request is received, the DME MAC shall determine if there is sufficient medical documentation that supports whether the item is reasonable and necessary. In addition, a review of the beneficiary's claims' history should be conducted in order to determine whether any other reason exists to cause the claim to be denied, e.g., whether same or similar equipment has already been provided.

Upon receipt of a request, the DME MAC shall render an advance determination of Medicare coverage within 30 calendar days. DME MACs shall provide the requestor with their decision, be it affirmative or negative, in writing.

Upon receiving an ADMC request, the DME MAC will review the information submitted with the request to determine if:

• A benefit category exists,
• A statutory exclusion exists, and
• The item is reasonable and necessary.

ADMC MR Decisions

An approved ADMC decision provides the supplier and the beneficiary assurance that the beneficiary will meet the medical necessity requirements Medicare has established for the item. This assurance is based on the information submitted with the request.

An approved ADMC decision does not provide assurance that the beneficiary meets Medicare eligibility requirements, nor does it assure that any other Medicare requirements (MSP, etc.) have been met. An approved ADMC decision also does not guarantee the price that Medicare will pay for the item. Only upon submission of a complete claim can the DME MAC make a full and complete determination.

A KX modifier may be added to the code on the claim for a power mobility device for an affirmative ADMC decision.

An affirmative ADMC decision is valid for a period of six months from the date the decision is rendered. Beneficiaries who require customized DME are subject to rapid changes in medical condition, which may allow the need for a particular item. For this reason, the date the item was provided to the beneficiary cannot be more than six months after the date the ADMC decision was rendered.

A negative ADMC decision indicates to the supplier and the beneficiary that the beneficiary does not meet the medical necessity requirements Medicare has established for the item. The negative decision is based on the information submitted with the request and should indicate why the request was denied.

Requests may be resubmitted once during a six-month period for a negative ADMC decision if additional medical documentation is supplied.

The DME MACs provide their decision to the requestor in writing, whether affirmative or negative. That information can be found through the Interactive Voice Response (IVR) system, Prior Authorization function, and speaking a verbal response of prior or a touch tone response of 1. The information that can be obtained is:

• Receipt Date
• Status (pending, affirmed, denied)
• Tracking Number

Questions

If suppliers have additional questions, call the Pre-Claim Hotline regarding the ADMC process or any negative or affirmative decisions.

Acceptable use of the hotline includes questions a supplier may have during the preparation of an ADMC submission, questions on a decision that was received or information on coverage criteria.

When calling the hotline number, the caller will be directed to a voicemail. He/she must provide the below information.

• Beneficiary Name
• Supplier Name
• Phone Number
• Hours of availability and time zone
• Beneficiary Medicare Number or Medicare Beneficiary Identifier (MBI), if applicable
• Brief description of the question/issue

A Clinical Reviewer will return each voicemail within five business days.

Resource

• CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.18