Redetermination Submission Tips - JA DME

A DME MAC Program Manager Update

In previous articles, we shared how the Noridian and CGS Program Managers oversee a variety of operational and collaborative workgroups that meet monthly to discuss opportunities for DME MAC process improvements across all four DME MAC jurisdictions.

In this article, the Program Managers want to share the most common reasons why a redetermination cannot be processed. Please keep the following tips in mind before you submit your redeterminations so that we can process your request in an efficient and comprehensive manner.

Redetermination Submission Tips

• Unprocessable claims contain message MA130 ("Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Submit a new claim with the complete/correct information.") cannot be appealed. Correct any errors and submit as a new claim.
• Include valid appellant signatures - Requests received without appellant's signature are dismissed as incomplete requests.
• Duplicate redetermination requests cannot be processed. Be sure to research to ensure that a redetermination request was not already submitted.
• Include proper and legible documentation such as medical records, prescriptions, refill requests, proof of delivery, Certificates of Medical Necessity (CMNs), DME Information Forms (DIFs), and/or the Advance Beneficiary Notice of Noncoverage (ABN) as appropriate. Do not include a corrected claim.
• If medical notes are handwritten and/or illegible, the appeal will remain denied as the medical documentation received is illegible. If any illegible documentation is submitted, it will be excluded as only legible supporting documentation is considered as part of an appeal request.
• Claims must be filed within one year of the date of service; please review the date of service prior to submitting the claim. If an act of nature, such as a flood, fire, or other circumstances outside of the supplier's control resulted in a timely filing denial, you can appeal the denial by providing a detailed explanation.
• If your claim denied because the beneficiary resides in a Competitive Bid area and the items were furnished by a non-contract supplier and you believe it was denied in error, before filing your redetermination, please:
  • Review the CMS DMEPOS Competitive Bidding - Home webpage or Competitive Bidding Implementation Contractor (CBIC) website to understand Competitive Bid rules and regulations.