Table of Contents. DME MAC Jurisdiction C Supplier Manual. Table of Contents. 1. Introduction
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1 DME MAC Jurisdiction C Supplier Manual Table of Contents 1. Welcome CGS s Role as a DME MAC What is Medicare? What is DME? Deductible and Coinsurance Eligibility Medicare ID Health Insurance Claim Number (HICN) and Medicare Beneficiary Identifier (MBI) The Medicare Card Termination of Enrollment Medicare Advantage Plans Other Government Insurance Plans Privacy Act of 1974 and HIPPA Privacy Rules Freedom of Information Act (FOIA) 2. Supplier Enrollment Overview National Provider Identifier (NPI) National Supplier Clearinghouse (NSC) Supplier Standards Reenrollment Change of Information Participating/Nonparticipating Site Visits Do Not Forward Directory of Medicare Suppliers Change of Ownership NSC Resources Supplier Audit and Compliance Unit (SACU) DMEPOS Accreditation Surety Bonds 3. Supplier Documentation General Information Definition of Physician Prescription (Orders) Requirements Spring 2018 DME MAC Jurisdiction C Supplier Manual Page 1
2 Documentation in the Patient s Medical Record Signature Requirements Refills of DMEPOS Items Provided on a Recurring Basis Beneficiary Authorization Proof of Delivery (POD) Advance Beneficiary Notice (ABN) Miscellaneous Documentation Issues Evidence of Medical Necessity: Power Mobility Devices (PMD) Comprehensive Error Rate Testing (CERT) 4. Certificates of Medical Necessity (CMNs) Certificates of Medical Necessity (CMNs) and DME MAC Information Forms (DIFs) CMN and DIF Completion Instructions CMNs as Orders and Claim Submission Oxygen CMNs CMN Common Scenarios 5. DMEPOS Fee Schedule Categories Inexpensive or Other Routinely Purchased DME (IRP) Items Requiring Frequent and Substantial Servicing Certain Customized Items Other Prosthetic and Orthotic Devices Capped Rental Items Oxygen Medicare Advantage Plan Beneficiaries Transferring to Fee-For-Service Medicare Supplies and Accessories Used with Beneficiary-Owned Equipment Repairs, Maintenance, and Replacement DMEPOS Competitive Bidding 6. Claim Submission Mandatory Claim Filing Assignment Agreement Administrative Simplification Compliance Act (ASCA) CMS-1500 Claim Form Guidelines for Filing Paper Claims Claim Completion Instructions Claim Filing Jurisdiction Time Limit for Filing Claims Clean Claims Payment Floor and Ceiling Spring 2018 DME MAC Jurisdiction C Supplier Manual Page 2
3 Electronic Funds Transfer (EFT) Place of Service Consolidated Billing DMEPOS and an Inpatient Stay DMEPOS and Hospice Upgrades PWK (Paperwork) Segment Electronic Submission of Medical Documentation (esmd) 7. Crossover Claims Coordination of Benefits Agreement Medigap 8. Electronic Data Interchange (EDI) Benefits of EDI ASCA Transmitting Claims to Other DME MACs Additional Electronic Options Additional Information 9. Coverage and Medical Policy 10. Pricing DMEPOS Benefit Categories Medical Review Program Medical Policies Advance Determination of Medicare Coverage (ADMC) for Wheelchairs Prior Authorization of Power Mobility Devices (PMD) Condition of Payment Prior Authorization (PA) Program: K0856 and K0861 Power Wheelchairs Denial Categories Fee Schedules Reasonable Charges Drug Pricing Single Payment Amount Individual Consideration Spring 2018 DME MAC Jurisdiction C Supplier Manual Page 3
4 11. Medicare Secondary Payer (MSP) Employer Sponsored Group Health Plan Coverage Accident/Injury Insurance Other Government-Sponsored Health Plans Electronic Billing of MSP Claims Medicare Secondary Claim Filing Tips MSP on Capped Rental Items MSP Payment Calculation MSP Overpayment Refunds Benefits Coordination & Recovery Center (BCRC) 12. Overpayments Overpayments and Refunds Overpayment Offsets Referral of Delinquent Debt Extended Repayment Plan Overpayment Appeals 13. Inquiries, Reopenings, and Appeals Telephone Inquiries Written Inquiries mycgs The Jurisdiction C Web Portal Provider Outreach and Education (POE) Department Reopenings for Minor Errors and Omissions Appeals Redeterminations Reconsiderations Administrative Law Judge (ALJ) Departmental Appeals Board Review Federal Court Review 14. Fraud and Abuse Unified Program integrity Contractors (UPICs) Defining Fraud and Abuse Procedures for Handling Fraud and Abuse Situations Protect Yourself from Fraud UPIC Contact Information Spring 2018 DME MAC Jurisdiction C Supplier Manual Page 4
5 15. Resources Durable Medical Equipment Medicare Administrative Contractors (DME MACs) Jurisdiction C Resources Additional Resources Web Resources 16. Coding The Pricing, Data Analysis and Coding (PDAC) Contractor Level II HCPCS Codes Coding Jurisdiction Modifiers 17. System Outputs 0BClaim Development Procedures 1BMedicare Summary Notice (MSN) 2BMedicare Remittance Notice (MRN) 3Biller Purged Claim Report 4BANSI Codes 18. Acronyms and Abbreviations Appendix A Level II HCPCS Codes Spring 2018 DME MAC Jurisdiction C Supplier Manual Page 5
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