Serial Claims Review Initiative - JA DME
Serial Claims Review Initiative
CMS is implementing changes to improve the processing and adjudication of Medicare Fee-For-Service (FFS) recurring (or serial) claims for capped rental items and certain Inexpensive and Routinely Purchased (IRP) items.
Initial Claim Processing
CMS considers serial claims to be claims that are so closely related to one another that the same payment decision should be applied to each claim. In general, serial claims are for the same HCPCS code and same beneficiary.
DME MACs are instructed by CMS to perform a pre-payment complex medical review on a claim line and then, based on the results of the complex medical review.
- Pay subsequent claims in the series after passing existing validation edits, OR
- Deny subsequent claims in the series unless the provider submits additional documentation with the subsequent claim line.
DME MACs update their claims processing system to reflect when a favorable decision has been rendered for a serial claim, allowing future claims in the same series to pay without requiring suppliers to continually resubmit evidence. This change will also ensure that items that have been subject to medical review and have been determined to meet medical necessity standards, will continue to be paid consistently for the duration of the rental period, in instances where the medical necessity decision is applicable to other claims in the series.
New or Additional Documentation Submission
Providers and suppliers should be aware that if a serial claim is denied after a complex medical review, subsequent claims in the series will be denied unless additional documentation is submitted to demonstrate that the services are reasonable and medically necessary. The process used to submit additional documentation will depend on how the claim is submitted:
- If a paper claim is submitted, any additional documentation must be attached to the claim form.
- If an electronic claim is submitted, the existing PWK process must be followed and the claim must also include the word "serial" in the NTE02 segment. (See CMS Medicare Learning Network (MLN) Matters (MM)7041 for the existing PWK process.)
Appeal Outcomes and Subsequent Claim Activities
Once the reason for denial for one claim in a series is resolved at any appeal level, the DME MACs will identify other claims in the same series that were denied for the same or similar reasons and will take that determination into consideration when adjudicating such claims. Specifically, the DME MACs will apply this process to:
- Claims pending redeterminations; and
- Claims in the series for which a redetermination was issued, but the timeframe to request a reconsideration by the Qualified Independent Contractor (QIC) has not yet elapsed.
The DME MACs will also communicate the favorable decision(s) to the DME QIC and the Office of Medicare Hearings and Appeals (OMHA) to consider when adjudicating related appeals pending at those levels.
Serial Claim Impacted HCPCS Listing
Resource
- CMS Change Request (CR) 10426 - Implementation of Automating First Claim Review in Serial Claims for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
