Durable Medical Equipment Medicare Administrative Contractors (DME MACs). Medicare contractors that educate Medicare suppliers, process claims and claim reopenings, and perform first level claim appeals called redeterminations.
On March 2, 2015 OMHA announced the implementation of the ALJ Appeal Status Information System (AASIS) Website. The AASIS website provides public access to appeal status information and is accessed through the OMHA website (http://www.hhs.gov/omha) by selecting the “Appeal Status Lookup” link located on the left navigation bar. Information on data availability, updates, and status definitions, is also provided to assist with your search.
AASIS allows users to query level 2 and/or level 3 appeal numbers and returns appeal data such as:
Date appeal received
ALJ assignment and team phone number
Table 3: Redetermination DME MAC Contact Information
Noridian JA DME Attn:DME Redeterminations PO Box 6780 Fargo, ND 58108-6780
When a Redetermination is filed it is imperative that you review all documents prior to submission to ensure they are applicable and meet CMS guidelines. Note that if you do not feel fully prepared for the Redetermination and you are close to the 120 day filing limit you should consider submitting the Redetermination even though you may be denied. CMS is stringent on the filing limit so it is better to submit the documentation you have knowing that you may have to go to Reconsideration to file the additional documentation once obtained.
Redetermination requests should include the following:
Verbal/dispensing order that includes: Patient Name, description of Item, prescribing physician’s name, date of order (and start date if start date is different from the date of order), suppliers signature on verbal orders or physician’s signature on written orders.
Detailed written order (DWO) which includes: Physician’s Name, physician’s signature and dated prior to the claim’s bill date, date of order (and start date if start date is different from the date of order), detailed description of the items ordered, dosage, route, frequency, duration, quantity to be dispenses, number of refills and length of need as applicable. Click here for additonal details on the elements of DWOs.
Beneficiary or authorized representative’s attestation of the refill request. The date of the request must be prior to the date of delivery and should be documented. The request must include a description of the items being requested and documentation that the supply is approaching exhaustion by the expected delivery date.
Proof of Delivery (POD) must following the regulations defined in the 3 methods of delivery. Click here for additional information on POD or see the Supplier Manual for full details. In general when delivered in person by the supplier the POD to a patient is the signed and dated delivery ticket (delivery slip). If using a shipping service or mail order, the POD documentation must be a complete record tracking the item(s) from the HIT/DME provider to the patient. Proof of Delivery must be closely adhered and should follow all guidelines set by CMS.
Pick up slip for previous equipment (if applicable)
Advanced Beneficiary Notice of Noncoverage (ABN) (if applicable). The ABN must be included if you are attempting to change a liability decision (from “CO” to “PR”) and must include all elements specified by CMS.
Correct diagnosis codes that are supported by documentation from the treating physician. The medical record submitted in the redetermination should support the change you are requesting to the diagnosis code.
Any information required for the use of specific modifiers as defined in certain DME policies. An example of this is the KX modifier. If this modifier is used you must have the documentation that supports the therapy.
Relevant medical records and related progress notes which include but not limited to physician’s office records, hospital records, nursing home records, home health agency records, records from other health care professionals and test reports. Read though the documentation you are submitting to ensure it is applicable to your case. Submitting documentation that is not relevant may cause delays in the Redetermination decision.
In order to support the case for a specific therapy additional documentation may be necessary and may include:
External Infusion Pump/Covered Drugs
DME Information Form (DIF) (should be signed/dated prior to the date of the claim submission)
Medical records that contain:
Documentation to support the Length of Need
Documentation to support the Diagnosis on the DIF
Documentation to support reported test results (such as those on the Inotropic Data Collection Form)
Date of the organ transplant
Documentation that the transplant was Medicare approved to have met the coverage criteria in effect at the time.
The patient was enrolled in Medicare Part A at the time of transplant
DME Information Form (DIF) must be signed/dated prior to the claim submission date
Specialty formulas: Documentation supporting the need for these categories (i.e., office notes, lab reports, progress notes, etc.)
Nutrition provided outside of Medicare’s recommended total caloric daily intake
Statement from the physician as to why lower/higher calorie intake is needed
Documentation that supports the criteria used to qualify the patient for TPN. The LCD & Policy Article provide specific information for each criterion.
Use the redetermination form but also include a cover letter to point out specifics in your documentation that demonstrates coverage criteria has been met
Send only related documentation
Do not highlight because highlighted sections are often illegible after the document is scanned
The suggested documentation items listed here are just that – suggested. It is important that you read the audit and submit all documentation requested in that audit. If you feel additional documentation not requested would help support your claim then you should submit it. In an appeal situation, you should determine which pieces of documentation will best support your appeal.