Billing Situations

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.

Break in Need or Service and Break in Billing - Break in Need or Service and Break in Billing are the most common situations for questions on what type of CMN/DIF/Order or what other information should be obtained/submitted on claims and what should be included in the narrative.

Certificates of Medical Necessity (CMNs) or DME Information Forms (DIFs) - A Certificate of Medical Necessity (CMN) or a DME Information Form (DIF) is a form required to help document the medical necessity and other coverage criteria for selected DMEPOS items. For certain items or services billed to a DME MAC, the supplier must receive a signed CMN from the treating physician or a signed DIF from the supplier.

Common Scenario Chart Requirement for Type of CMN/DIF/Order and Additional Information When Billing Claims - Chart provides the common scenarios with guidance on the type of CMN/DIF/Order those situations require and what type of narrative may be required when billing.

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 Thu, 03 Jun 2021 12:59:04 +0000