Article Detail - JD DME

Posted September 28, 2012

Beginning October 01, 2012, Suppliers will have the option of mailing or faxing hard copy documentation to accompany their electronically-submitted DMEPOS claims. Use of the PWK segment is completely voluntary and does not guarantee that the DME MAC will review the submitted paperwork. When processing claims, the DME MAC may look for additional information in the NTE segment or the PWK segment in order to complete the claim; however, use of the PWK segment does not mean that the DME MAC will always review the information. The DME MAC will only look at the additional information when needed in order to properly process payment.

DME MAC Jurisdiction A encourages suppliers to continue to use the NTE segment if that method of conveying additional information for your claim submissions has been effective.

If a supplier chooses to submit information using the PWK process:

1. The electronic claim is submitted, completing the PWK segment (use BM if mailing the documentation, or FX if faxing)

2. After the claim has been accepted by CEDI, complete the PWK Fax/Mail Cover Sheet, available on the CMNs and Forms page of the DME MAC A web site

3. Fax or mail the PWK Cover Sheet with all necessary documentation

• Medicare contractors will allow seven calendar "waiting" days (from the date of receipt) for additional information to be faxed or ten calendar "waiting" days for additional information to be mailed

4. The DME MAC will process the claim and will refer to the submitted PWK documentation, if needed, for proper claim adjudication

When considering whether or not to use the PWK segment, please keep the following tips in mind:

•Use of the PWK segment is entirely voluntary o Suppliers are not required to use the PWK segment in any circumstance; it is entirely voluntary. Under current claim processing rules, if a Medicare contractor determines that additional information is needed to complete proper adjudication of a claim (for instance, due to an audit), then the contractor will send you a development letter requesting additional documentation. This process will not change. If you believe the claim may result in a development request, then it may be a good idea to include the documentation through the PWK process in order to expedite claim processing time. Please keep in mind that most often; claims are randomly selected for audits so a supplier would not necessarily know in advance that a claim will be selected for a prepayment review.

•The NTE field is still the best option to submit additional information o Using the PWK segment is not always the best option for including additional claim information. The NTE (note) segment of an electronic claim is currently available for you to include notes and information that may be important for the proper adjudication of the claim. The NTE segment will continue to be available.

Use of the PWK segment results in additional processing time due to the waiting period required for us to receive your mailed/faxed documentation. If you can use the NTE segment instead of the PWK segment, we encourage you to do so.

•Use of the PWK segment does not guarantee that the DME MAC will review the submitted paperwork o When processing your claims, NHIC, Corp. DME MAC may look for additional information in the NTE segment or the PWK segment (beginning October 1) in order to complete the claim; however, use of the NTE segment or PWK segment does not mean the information will always be reviewed. The additional information will only be reviewed when needed in order to properly process payment. For instance, if a claim is submitted with a modifier that precludes payment for the item, the claim will deny without our claim processors looking at the NTE or PWK segments.

•Do not send PWK documentation unless it is needed o Medicare rules and regulations require that suppliers keep certain documentation on file in order to support the medical necessity and justification of your claims (detailed written orders, proof of delivery, etc.); however, you are not required to submit this documentation with your claim. We encourage you to only submit supporting claim documentation when you believe we require it in order to correctly process the claim.

The DME PWK Coversheet is available on the CMNs and Forms section of the NHIC, Corp. DME MAC web site.

Additional information about the use of the PWK segment is available in MLN Matters Article MM7041 and MLN Matters Article MM7306.