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 information should be obtained/submitted on claims. All CMN/DIF/Order requirements detailed below are based on assumptions about the most frequently given scenarios. Suppliers should use this information only as general guidance and should consult with the appropriate DME MAC Supplier Contact Center as necessary for additional questions of slight differences in your specific scenario. Below is some guidance defining Break in Need or Service and Break in Billing.

Break in Need or Service Means

  • More than 60 days with Change in Medical Condition with new rental item being provided.
    • Original rental item was returned to supplier as the beneficiary no longer required the item (medical necessity ended.) Medical need now exists with new rental item being provided.
  • Required when Billing Claim
    • The supplier obtains/submits new initial CMN/DIF/Order or medical necessity documentation and a narrative to claim explaining why there was a break in need for the equipment (BIS)
    • The contractor determines that there was a break in need of greater than 60 days plus the days remaining in the last paid rental month followed by a resumption in medical necessity for the equipment.
    • If claim denies, submit an appeal with all documentation to support medical need

Break in Billing Means

  • More than 60 days with no change in medical condition
  • Less than 60 days with or without change in medical condition
    • This means that there is a break in the billing of the claims. Examples include the beneficiary entered a hospital stay, Skilled Nursing Facility (SNF), or joins a Medicare Advantage Plan and continues to need/use the equipment. When the beneficiary returns or rejoins Medicare Fee-for Service (FFS), payment resumes where it left off. This could also include situations in which the beneficiary continued to need the equipment.
  • Required when Billing Claim
    • A new initial CMN is not required and should not be submitted
    • Add Narrative to claim explaining why there was a break in billing (BIB)
    • If claim denies, submit an appeal with all documentation to support medical need

 

Last Updated Thu, 03 Jun 2021 12:47:37 +0000