Medical Review - JA DME

Q1. What are probe reviews?
A1. Probe reviews are medical record reviews conducted to validate a hypothesis that claims are being billed in error. These reviews can be completed on a prepayment or post-payment basis. Suppliers are notified in writing that a probe review is being conducted and are asked via Additional Documentation Request (ADR) letters to provide medical record documentation for the claim(s) in question. Suppliers are also notified of the results of the review. Currently the only probe reviews conducted by Noridian are Targeted Probe and Educate (TPE). See the Targeted Probe and Educate (TPE) webpage for more information.

Q2. What is the difference between a prepayment and post-payment medical record review?
A2. A prepayment review occurs when a reviewer makes a claim determination before a claim payment has been made. Prepayment review always results in an "initial determination."

Post-payment review occurs when a reviewer makes a claim determination after the claim has been paid. Post-payment review results in either no change to the initial determination or a "revised determination" indicating that an overpayment or underpayment has occurred. A listing of current post-payment reviews can be found on the Medical Record Review Results page.

For more information on types of reviews, see CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3

Q3. If a supplier receives a Medical Record Review denial and would like further information, can he/she speak to the nurse that reviewed the claim?
A3. Yes. A supplier may call the Supplier Contact Center and request to speak to the nurse that reviewed the claim. When the nurse receives the request, he/she will return the call. Suppliers are also able to view the nurse's comments on the denied claim via the Noridian Medicare Portal (NMP). In NMP, users can go to Claim status > Inquiry > View claim > Noridian Comments. The NMP End User Manual also includes all function details. Note: If a supplier is part of a TPE review, call the case manager with questions related to that case.

Q4. What letters can be viewed in the Noridian Medicare Portal (NMP)?
A4. The ADR, Notification letters, Findings Letters, Comprehensive Billing Reports, Provider Billing Analysis letters and Full Remittance Advices can all be viewed in the NMP. Suppliers may also submit their documentation via the NMP to respond to the ADR letter. View ADR Submission and Status webpage for instructions on how to view and submit documentation.

Q5. How can a supplier determine if there has been a same or similar item provided to a beneficiary during the reasonable useful lifetime?
A5. Suppliers can check for same or similar items using NMP. To search the beneficiary's history within NMP, users can go to the Same or Similar DME tab and choose "Same or Similar" or "Code Range Search." Same or similar can also be verified using the interactive voice response (IVR).

Advance Determination of Medicare Coverage (ADMC)

Q1. Is an ADMC required?
A1. No. This is a voluntary program. Beneficiaries and suppliers are not required to submit ADMC requests to submit claims.

Q2. What DME is eligible for an ADMC?
A2. For the list of eligible HCPCS, the process, and decisions, see the Advance Determination of Medicare Coverage (ADMC) webpage.

Q3. What is the life expectancy of a wheelchair?
A3. According to the CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 100.2 (C): The reasonable useful lifetime of durable medical equipment is determined through program instructions. In the absence of program instructions, carriers may determine the reasonable useful lifetime of equipment, but in no case, can it be less than five years. Computation of the useful lifetime is based on when the equipment is delivered to the beneficiary, not the age of the equipment. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary. A new physician's order is required before replacing lost, stolen or irreparably damaged items to reaffirm the medical necessity of the item. Proof of loss or damage through documentation such as a police report, picture, or corroborating statement should be submitted or noted on the claim.

Q4. When submitting an ADMC, can suppliers use Not Otherwise Classified (NOC) codes?
A4. Yes, if there is not a code assigned to the item, suppliers may use a NOC code. Provide a detailed description of the item requested and explain why this item is medically necessary. Also, provide an invoice or the Manufacturer's Suggested Retail Price (MSRP). An example of using a NOC code would be a customized item for the beneficiary's needs.

If a supplier is uncertain about proper codes for DMEPOS items, see the Pricing, Data Analysis Contractor (PDAC) website. If a HCPCS code exists for an item, using HCPCS K0108 is not correct. See the CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.18

Q5. An ADMC request was denied because basic documentation was not submitted. The physician signed the form agreeing with the information on it and it was sent. Why is this not sufficient?
A5. According to the CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.9, for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the his/her medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient's diagnosis and other pertinent information including, but not limited to, duration of his/her condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. Neither a physician's order, a CMN, a DIF, a supplier prepared statement or a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician.

Q6. How long are suppliers required to wait to receive notification of the ADMC decision?
A6. According to the CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.18.3, the DME MAC must render an ADMC decision within 30 calendar days of receipt.

Q7. When a supplier is requesting an ADMC for a new chair, why must the DME MAC know the status of the current chair?
A7. The DME MAC must determine that the beneficiary's current mobility related activities of daily living (MRADLs) are not being met by his/her current equipment.

Prior Authorization (PA)

Q1. Is a PA required?
A1. As described in 42 C.F.R. §414.234, if an item is selected for required PA under the program, then submitting a PA request is a condition of payment. Therefore, claims for items subject to required PA that are submitted without a PA determination and a corresponding Unique Tracking Number (UTN) will be automatically denied.

View the Required Prior Authorization webpage for program details.

Q2. How does a supplier bill the PA item following an affirmed decision by the DME MAC?
A2. The DME MAC will provide the UTN on the PA decision letter that is sent to the PA request submitter. The supplier shall then render the DMEPOS item to the beneficiary after receiving the PA decision and submit the claim with the UTN on the claim. When billing a series of claims: Submit the UTN on each claim in the series and to the applicable DME MAC for adjudication. For submission of a claim on the CMS-1500 Claim Form, the UTN is submitted in the first 14 positions in Item 23. All other data submitted in Item 23 must begin in position 15. For submission of electronic claims, the UTN is submitted in either the 2300 - Claim Information loop or 2400 - Service Line loop in the Prior Authorization reference (REF) segment where REF01 = "G1" qualifier and REF02 = UTN.

Q3. If I have coverage criteria questions related to PA or ADMC is there a number to call?
A3. Yes. Suppliers may call the Pre-Claim Hotline to ask questions on decisions rendered via ADMC or PA. Beneficiary inquiries must be directed to 1-800-Medicare. General questions on coverage criteria for mobility devices, lower limb prosthetics, orthotics, or pressure reducing support surfaces may also be directed to the Pre-Claim Mobility Hotline. It is not to be used for status inquiries or to request copies of decision letters. See the Pre-Claim webpage for more information.

Q4. Can providers/physicians get a copy of the PA decision letter?
A4. Yes, providers/physicians may request a copy of the PA decision letter. Per the Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items-Operational Guide "Providers/physicians requesting decision letters must be able to demonstrate a legitimate, specific need for the information requested, and if so substantiated, contractors shall ensure that the information provided is sufficiently tailored to comply with Health Insurance Portability and Accountability Act's minimum necessary standards and other applicable laws or regulations."

Q5. Can I submit a PA request via NMP?
A5. Yes, PA requests can be submitted via the NMP for any item in the PA program. NMP users can also view decision letters, check the status of the PA request, view clinical reviewer notes, and add/view additional documentation. See the Prior Authorization Request Status and Submit New Prior Authorization Request webpage for more information.

Q6. How long are suppliers required to wait to receive notification of a PA decision?
A6. Per the Prior Authorization Process for Certain DMEPOS Items-Operational Guide the DME MAC has 10 business days to review an initial and a subsequent PA request for Power Mobility Devices and Lower Limb Prosthetics. For Pressure Reducing Support Surfaces: Group Two and select Spinal and Knee Orthotics, the DME MAC has five business days for initial and subsequent PA requests.

Q7. How will the PA decision be received?
A7. The Noridian Medicare Portal will display the PA decision once the request has been processed. A decision letter is also mailed to the supplier for every PA request.

Q8. Is a prior authorization required when Medicare is Secondary?
A8: Yes, prior authorization is required in order to bill Medicare. If Medicare coverage requirements are met, this assures all parties that Medicare will cover the item should the primary insurance deny payment.

Q9. Why is the prior authorization request denied when an orthosis is needed for surgery?
A9. Medicare does not pay for an item until the procedure that makes the item necessary occurs. Medical record documentation must support the medical necessity of the item at the time the item is delivered. There would be no medical need for the orthosis until the surgery takes place.

Q10. What if a beneficiary needs an orthosis sooner than the 2-day expedited timeframe?
A10. Due to the need for certain patients to receive an orthoses item that may otherwise be subject to prior authorization when the 2-day expedited review would delay care and risk the health or life of the beneficiary, prior authorizations may be suspended under limited circumstances. More information may be found in the Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies DMEPOS) Items Operational Guide.

Q11. Am I able to request a review of PMD accessories?
A11. Yes. To request a voluntary review of accessories, suppliers must select the box indicating "review eligible accessories" on the coversheet or NMP when a PMD wheelchair base PA is submitted. The DME MACs will reject requests for accessories when there is no PMD wheelchair base on the request or there is an affirmed PA request on file. The list of eligible accessories is located in the Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items Operational Guide.