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Billing Situations

Topic Brief Description
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. 

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 Plan

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.

 

Last Updated Jun 14, 2016