Article Detail - JD DME

Consider the questions below prior to providing Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) items, and to gain the necessary information to determine whether an item may be considered same or like equipment already obtained.

Has the beneficiary had a same or similar item paid for by Medicare Fee for Service (FFS)? Verify prior to providing item.

• The Noridian Medicare Portal can be accessed under Same or Similar, option 2 to verify same or similar or
• Call the Noridian Interactive Voice Response (IVR) System for same or similar
  • If they have not had a same or similar item, bill claim without obtaining an ABN (no ABN necessary)
  • If they have had a same or similar item, determine if item has reached its Reasonable Useful Lifetime (RUL)
    • If RUL reached, bill claim without ABN (no ABN necessary)
• Has there been a change in the beneficiary's medical condition that supports the need for a same or similar type of item?
  • If item has not reached RUL, obtain an ABN and all medical records to support the change in medical condition requiring replacement
• Has the original item been lost, stolen, or irreparably damaged?
  • Include the RA modifier and a narrative description on the claim explaining why the equipment is being replaced. Suppliers should maintain documentation indicating that the item was lost, destroyed, irreparably damaged and the details of the incident (e.g., police report, insurance claim report or beneficiary statement) in the medical record.

Answering these questions will help determine whether an Advance Beneficiary Notice of Noncoverage (ABN) should be obtained

Common Reasons for Denial:

• Item billed matches one already received by beneficiary.

Resolving Denial

• Appeal claim with all relevant supporting documentation. Noridian encourages Redeterminations/Appeals submission through the Noridian Medicare Portal.