Requirement of New Orders
A new order is required:
- For all claims for purchases or initial rentals
- If there is a change in the order for the accessory, supply, drug, etc.
- On a regular basis (even if there is no change in the order) only if it is so specified in the documentation section of a particular medical policy
- When an item is replaced
- When there is a change in the supplier, and the new supplier is unable to obtain a copy of a valid order and documentation from the original supplier.
A new order is required when an item is being replaced because the item is worn or the beneficiary's condition has changed. The supplier's records should also include beneficiary-specific information regarding the need for the replacement item. This information should be maintained in the supplier's files and be available to the DME MAC, and Zone Program Integrity Contractor (ZPIC) on request. Failure to provide the appropriate documentation or providing documentation that contains broad, nonspecific explanations will result in a claim(s) denial.
A new order is required before replacing lost, stolen, or irreparably damaged items to reaffirm the medical necessity of the item. Proof of loss or damage through documentation such as a police report, picture, or corroborating statement should be submitted with the claim.
For items that require a Certificate of Medical Necessity (CMN), the CMN may serve as the written order if the narrative description in Section C is sufficiently detailed. If the item requires a written order prior to delivery and the supplier uses the CMN as the written order, the supplier must have received the fully completed CMN (original "pen and ink," electronically maintained, photocopy, or facsimile image) before dispensing the item. For accessories, supplies, and drugs related to an item requiring a CMN, the CMN may serve as the written order if the narrative description in Section C is sufficiently detailed.
Affordable Care Act and New Orders
The Affordable Care Act (ACA) Section 6407 requires a face-to-face encounter to occur within 6 months prior to the written order prior to delivery (WOPD) for certain DME items listed within it. This requirement applies any time a new order has been obtained for the purposes of Medicare payment. The only exception to the requirement for a face-to-face encounter within 6 months is when a new order is obtained due to state law, and the order is not being used as documentation to support a claim for Medicare payment. If the order is being used to meet a Medicare requirement, a new face-to-face must be conducted.
If a new order is being used as documentation to support continued medical need or to fulfill any other documentation requirement for Medicare payment, then a face-to-face encounter within 6 months prior would be required.
- CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual (PIM), Chapter 5, Section 5.2.4
Last Updated Dec 19, 2019