Billing Situations

Back-Up Equipment - Identical or similar device that is used to meet the same medical need for the beneficiary but is provided for precautionary reasons to deal with an emergency in which the primary piece of equipment malfunctions.

Beneficiaries Entering Medicare - When a beneficiary receiving a DMEPOS item from another payer (including a Medicare Advantage plan) becomes eligible for the Medicare FFS program, the first Medicare claim for that item or service is considered a new initial Medicare claim for the item.

Beneficiary-Owned Equipment When Billing for Accessories and Supplies - Beneficiary-owned equipment must be on file with Medicare Fee-for-Service (FFS) to avoid denials.

Billing Not Otherwise Classified (NOC) HCPCS Code - Requirements when billing Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) submitted with a Not Otherwise Classified (NOC) HCPCS Code.

Break in Need or Service and Break in Billing - Break in need/service and break in billing are the most common denials when billing claims. Break in need/service and/or billing is defined as a temporary interruption in the use of equipment.

Canceled Orders for Customized Items - When an order for a customized item is canceled, the beneficiary passes away before the scheduled delivery or the beneficiary's condition changed and the item is no longer reasonable and necessary or appropriate, suppliers are eligible for reimbursement for the labor and parts invested in the customization process.

Consolidated Billing - The criteria for Skilled Nursing Facility and Home Health Agency consolidated billing and related resources is provided.

DMEPOS and Inpatient Stays - This page contains guidance on pre-discharge delivery, conditions, date of service, facility responsibilities, immunosuppressive drugs, and claims during the inpatient stay for DMEPOS.

Federal Black Lung - This program covers Black Lung claims.

Hospice - Any covered Medicare services not related to the treatment of the terminal hospice condition and which are furnished during a hospice election period, may be billed to Medicare for payment.

Indian Health Services (IHS) - View information about the provision that allows IHS facilities to bill the DME MAC for certain Durable Medical Equipment.

Informational Unsolicited Response (IUR) - The IUR process identifies and performs retroactive adjustments on any previously paid claims which may have been processed and paid erroneously during periods when the beneficiary data in the Enrollment Database did not reflect the fact that the beneficiary was incarcerated.

Medicare Advantage Plans - Payment cannot be made under FFS Medicare for beneficiaries enrolled in a Medicare Advantage Plan, also referred to as Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).

Medicare HMO Beneficiaries Transferring to Fee-For-Service Medicare - If a beneficiary received any items or services from their HMO or Managed Care plan, they may only continue to receive such items and services if they would be entitled to them under FFS Medicare coverage criteria and documentation requirements.

New Capped Rental Period - This section defines two major reasons a new rental period would begin for a similar (same code) or related (different code) item of DME that is in the Capped Rental payment category.

Qualified Medicare Beneficiary (QMB) Program - "Dual-eligible beneficiaries" are individuals enrolled in both Medicare and Medicaid. This includes beneficiaries who are enrolled with Medicare Part A and/or Part B who also receive Medicaid benefits or assistance with Medicare premiums, or cost sharing through various programs. One program is the Qualified Medicare Beneficiaries (QMB) Program which assists low-income beneficiaries with their Medicare premiums and cost sharing.

Traveling/Snowbird Beneficiary - The beneficiaries permanent address on file with Social Security Administration determines which jurisdiction should be billed.

Last Updated Apr 01 , 2024