Region D DAC
Region D DAC
Questions for Noridian and CMS
Atlanta World Congress Center
29 October, 2008
NOTE: THIS INFORMATION SHOULD NOT BE FORWARDED OUTSIDE THE DAC AS IT IS IN DRAFT FORMAT ONLY.
RESPIRATORY
Leader: Gemma English
Assistant Leader: Colleen McKenna Shaw
Executive Committee Contact: Carlos Reyes
1. In the transition to the PDAC, the code A9279 (monitoring feature/device) has been discussed in the supplier community. Is this code in current use and if so is it required for sleep machines, apnea monitors and other pieces of equipment that have the availability to capture data? Can you further clarify where and if this code should be used.
NAS Response: A9279 is a valid code per the HCPCS book; however it is a non-covered code by Medicare. This question was recently addressed in the article on FAQs for Positive Airway Pressure Devices, published on our web site on 9/17/08, as listed below:
10. Has there been any consideration to paying for A9279 - Compliance monitoring equipment or component of equipment, to compensate for the additional work on the part of the supplier associated with compliance in the initial 90-day trial period?
Answer: This was considered; however, it has been decided that A9279 will continue to be non-covered by Medicare.
2. Providers have noticed when submitting claims for BiPAP ST's that most are being downcoded to an E0470 or regular BiPAP. The KX modifiers are attached as well as the correct dx chosen. Remittance advice shows E0470CC so the claim is being downcoded by NAS. Examples can be provided if necessary.
NAS Response: The medical policy for E0471, BiPAP ST’s states the following:
“A RAD with backup rate (E0471) is not medically necessary if the primary diagnosis is OSA; therefore, if E0471 is billed with a diagnosis of OSA, the following payment rules apply:
If criteria A - D above are met, payment will be based on the allowance for the least costly medically appropriate alternative, E0470; or,
If criteria A-C above are met but not criterion D, payment will be based on the allowance for the least costly medically appropriate alternative, E0601.”
Examples were requested from the DAC office on 9/2308 to be faxed to Janet Kirsch at 701-433-3063 and to date (10/13/08) none have been received. NAS will need examples to research further.
IV /PEN
Leader: Deanne Birch
Assistant Leader: Rosalee Weber
Executive Committee Contact: Troy Paz
3. In receiving short-pays and denials for enteral claims where the patient is using >2,000 calories per day, Nordian is referencing the IOM, Publication 100-4, Chapter 20, Section 100.2.2.2 which indicates the reason for a daily caloric intake >2,000 cals must be documented in the patient’s medical record by the treating physician. The same manual reference still requires a CMN for enteral and appears to be outdated. Is this still a requirement? Where can we reference this rule? The LCD does not require such documentation.
NAS Response: The exact reference for the CMS Medicare Claims Processing Manual, as referenced above is as follows and can be found at cms.manuals/downloads/clm104c20.pdf
“Generally, daily enteral intake of 750 to 2,000 calories is considered sufficient to maintain body weight. Patients with medical complications may require an intake outside the range. The attending physician must document the reason for prescribing less than 750 calories per day or more than 2000 calories per day. “
We will contact CMS about updating this same section of the manual to change the wording from CMN to DIF but this calorie guideline is not outdated. Even though this is not referenced in the LCD, this is still a CMS guideline. Medical necessity for calories over 2,000/day or less than 750 calories/day should be documented by the treating physician. This documentation should be available upon request or submitted when requesting an appeal of a denied enteral claim.
Additional Question
We would like to ask Noridian to consider updating the LCD in regard to the requirement for >2000/day. Most providers look to the supplier manual and the LCD for coverage & criteria determination. We would not necessarily refer to the CMS guidelines. We would like to see this information added to the LCD so we are clear on the requirements for formula >2000/day and/or under < 750.
NAS Response: Again, medical necessity for calories over 2,000/day or less than 750 calories/day should be documented by the treating physician, and will vary with the patient’s body mass and the clinical circumstances, which the physician’s record should make clear. It does not appear necessary or helpful to change the LCD at this time as NAS will be looking at this further and will provide further direction.
4. Regarding the proper pump used to administer vivaglobin, the external infusion pump policy states: Subcutaneous immune globulin is administered using ambulatory infusion pump E0779. Claims for usage of infusion pumps other than E0779 will be denied as not medically necessary. Some patients have become accustomed to using a cadd pump (E0781) for this service in their homes. Can a provider bill for a free upgrade in this instance? For example E0779 GL. Also, Vivaglobin is not always administered over 8 hours-please help us understand why E0779 defined below: E0779 Ambulatory
Infusion pump, mechanical, reusable, for infusion 8 hrs. or greater. Is this the only code payable for the administration of Vivaglobin? Does this mean that if the order is less than 8 hours the patient does not meet Medicare criteria as outlined in the external infusion pump policy?
REHAB
Leader: Leslie Rigg
Assistant Leader: Evan Call
Executive Committee Contact: John Kenny
5. Does the ATS requirement for providing Group 2 SP PWCs and above apply to a dealer who is retrofitting a power positioning system on a client owned base?
NAS Response: Yes. The LCD for Wheelchair options/accessories specifies that an ATS or ATP must be involved in the selection of power tilt and/or recline seating systems.
6. On May 09, 2008 Jurisdiction A published the following: Guidance on Billing Claims for E1028 When Used for Multiple Items
Code E1028 is defined as a wheelchair accessory, manual swing-away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory. Multiple items may be billed using this code. When submitting a claim for any number of claim lines for code E1028, the following instruction must be applied:
1. Each different item that is billed as an E1028 must be on a separate claim line.
2. Each E1028 claim line must include a narrative description of the item, the brand name, the make/model and the part number.
If billing electronically, details should be notated in the NTE 2400 segment of the electronic claim. For paper claims, details must be provided as an attachment. Claims submitted without this required information will be denied.
Does Jurisdiction D follow the same guidelines?
NAS Response: Yes, NAS follows these same guidelines. Whenever a code can be used for multiple items, a description of exactly what was provided should be submitted on the claim, along with submitting multiple lines for each component described by the code. If the description fits in Item 19 on the claim form, an attachment may not be needed. One would need to distinguish each line of the claim in Item 19, however, such as
Line 1: Mounting hardware for joystick, brand name, make/model and part #.
Line 2: Control interface for joystick, brand name, make/model and Part #.
7. K0830 POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 126 TO 300 POUNDS
K0831 POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 126 TO 300 POUNDS
These codes include a power elevating seat (PES). In general, any item that was considered “standard” on a base could not be billed separately; however, the policy states that these two items will be downcoded to the least costly medically appropriate alternative, i.e. K0822 or K0823. When providing a K0830/K0831 would it be acceptable or correct to bill for the power elevating seat using code E2300, even if the PES was considered a standard item on the base?
NAS Response: No. Where an item is considered standard it should not be separately billed.
8. The PMD LCD states that “the wheelchair must be provided by a supplier that employs a RESNA-certified Assistive Technology Supplier (ATS) specializing in wheelchairs who is directly involved in the wheelchair selection for the patient” for patients receiving a Group 2 single power option or multiple power option PWC, any Group 3 or Group 4 PWC, or a push rim activated power assist device for a manual wheelchair. In Alaska there are currently only 5 ATSs. 4 of the ATSs are in Anchorage and 1 is in Palmer, which is 42 miles northeast of Anchorage. For example, beneficiaries that live in Ketchikan, AK that need complex rehab products are 1,130 miles from Anchorage and 1,101 from Seattle, which are the two areas that currently have RESNA certified individuals. In order for an ATS from either of these two areas to see a disabled beneficiary in Ketchikan they must fly by prop plane or take a 2 day ferry ride to the beneficiary. This has created a severe access issue as the beneficiaries are physically unable to travel to the ATS and the ATS cannot afford to spend the travel time or money to go to the beneficiary’s home to evaluate them with the therapist. What does NAS recommend in order to be in compliance with the policy requirement for individuals in rural areas?
NAS Response: Remote locations often have access problems for clinical, as well as for other supplies and services. A fairly common concern in areas in Alaska, as well as even more remote locations, such as the US Territorial islands. Nonetheless, clinical and quality standards and requirements need to be maintained.
9. Noridian recently released a memo indicating that Labor was not an acceptable charge in the replacement of batteries. In our example, a quadraplegic needs replacement batteries for his patient owned power wheelchair which was funded by Medicare. Assuming the coverage criteria is met, and in view of Noridian’s claim that these could be installed by a non skilled technician, would it be appropriate to expect the beneficiary to install the batteries themselves? Does Noridian expect a non-skilled person to install the batteries if the installation requires the removal of other components of the wheelchair that may be technical in nature in order to access the batteries? If a skilled technician performs this work, would it be appropriate to use an ABN to advise the beneficiary that labor charges for battery replacement may not be covered?
NAS Response: The article referenced, titled Billing for Repairs and Labor, posted to our web site on 8/14/08, does not state that labor was not an acceptable charge in the replacement of all batteries. The article stated the following:
“E1340 requires the skill of a technician. Replacing batteries or other simple adjustments that do not require the skill of a technician are not covered by Medicare.”
This direction comes from CMS, in the Medicare Benefit Policy Manual, Chapter 15, Section 110.2, and is not a new guideline.
A quadraplegic may need to ask for help in replacing batteries from a caregiver, family member of neighbor. If a skilled technician is needed to replace wheelchair batteries, this will be covered by Medicare. If a non-skilled technician is not required and the beneficiary requests that the supplier perform this, it would be acceptable to obtain an ABN.
10. CR5537, published when code E2377 was implemented for the expandable controller, stated that code E2399 should be used for the upgraded proportional joystick and electronics/cables/junction boxes since they were not included in the allowable for E2377. The DME MACs all recently published articles stating that in these cases, from now on, instead of E2399, providers should use the following:
E2313 - POWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADE TO EXPANDABLE CONTROLLER, INCLUDING ALL FASTENERS, CONNECTORS AND MOUNTING HARDWARE, EACH.
However, E2399 included the upgraded proportional joystick and electronics/cables/junction boxes per CR5537. E2313, which is replacing E2399, only includes the harness, and does not address the joystick, which seems to have been left off of the description. If it actually replaced E2399, it should have read E2313 - Upgraded proportional joystick and electronics/cables/junction boxes used with expandable controller.
A solution would be to either allow E2399 to continue to be used for those parts originally covered by E2399 but not included in E2313, or develop a code for those parts not covered.
NAS Response: When CMS changed the code E2399 to new code E2313, it was intended that all items in code E2399 continue to be covered by the new code E2313. They did shorten the descriptor slightly for ease of use, but the code encompasses the same items.
11. The code for power elevating legrests reads as follows: E1010 – Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair. This description has been changed from its original description, which had read almost exactly the same with one exception. The previous description read 'each' as opposed to the current version (of 'pair'). Virtually all accessories that are applications for the lower extremities are listed as 'each'. This is a logical application as there will be situations where a beneficiary may only have a need for one item (the most straightforward example being a beneficiary that has a unilateral amputation). Additionally, when the description for this item was changed from 'each' to 'pair' the fee schedule remained unchanged, so the reimbursement rate was in effect inadvertently cut in half, and still has yet to be addressed. It is our recommendation that the description of this item be changed back to its original version of 'each' and the fee schedule kept intact as it is for all intents and purposes an allowable for a single power ELR.
NAS Response: The original description did read “each”, this is correct, but the pricing had been set up as “pair”, so the change in the E1010 code descriptor really maintains the same effective pricing all along.
HME
Leader: Marshall Pollock
Assistant Leader: Sha Eppley
Executive committee Contact: Barb Stockert
12. Please explain the Signature Requirements CR5971. Providers do not understand the history of this message. Stamped signatures on CMNS were allowed in 2006 (see old 2004 DMERC language and 2006 DMERC language attached). Additionally, the PIM (Program Integrity Manual) chapters 3 and 5 conflict with each other. Additionally, from the July 31, 2008 DAC call, we are curious if this CR 5971 is the answer to question#4, which could not be answered at the time?
(Note that items in red are this way due to the view presented by the PIM):
3.4.1.1 - Documentation Specifications for Areas Selected for Prepayment or Postpayment MR
(Rev. 248; Issued: 03-28-08; Effective Date: 09-03-07; Implementation Date: 04-28-08)
B. Signature Requirements
Medicare requires a legible identifier for services provided/ordered. The method used shall be hand written or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes.
NOTED EXCEPTION: Facsimile of original written or electronic signatures are
Acceptable for the certifications of terminal illness for hospice.
Providers using electronic systems should recognize that there is a potential for misuse or abuse with alternate signature methods. Facsimile and hard copies of a physician’s electronic signature must be in the patient’s medical record for the certification of
terminal illness for hospice. . . .
Note that this instruction does not supersede the prohibition for certificates of medical necessity (CMNs) and DME MAC information forms (DIFs). CMNs and DIFs are forms used to determine if the medical necessity and applicable coverage criteria for durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) have been met.
5.3.1 – Completing a CMN or DIF
(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)
The "Initial Date" found in Section A of the CMN, should be either the specific date that the physician gives as the start of the medical necessity or, if the physician does not give a specific start date, the "Initial Date" would be the date of the order.
The "Signature Date" is the date the physician signed and dated Section D of the CMN. This date might not be the same as the "Initial Date", since the "Signature Date" must indicate when the physician signed Section D of the CMN. Medicare requires a legible identifier for services provided/ordered. The method used (e.g., hand written, electronic, or signature stamp) to sign an order or other medical record documentation for medical review purposes in determining coverage is not a relevant factor. Rather, an indication of a signature in some form needs to be present. Do not deny a claim on the sole basis of type of signature submitted. Signature and date stamps are acceptable for use on CMNs and DIFs.
NAS Response: CR5971 was not the answer to #4 from the July 31 call. This was issued by CMS before we had the call and caused some of the confusion.
In the Special Edition MLN Matters article related to CR5971, SE0829, CMS stated that stamped signatures are not allowed on any medical record. They were silent about whether this was allowed for CMNs and DIFs. Per conversations with CMS and review of a draft CR, they will be clarifying in the future that stamped signatures are not allowed on either CMNs or DIFs. This will mean that across the board stamped signatures are not allowed on any type of documents. CMS should allow at least 30 days notice before this goes into effect.
13. Please address the issue of why claims for Bionicare, electrotherapy used in the treatment of pain due to Osteoarthritis of the Knee, are being categorically denied as not reasonable and necessary?
a. It appears these are being automatically denied at the first level of claims processing. Are these being auto-denied or denied status post manual claim or desk top review?
b. If the denial is after manual review, is the review being conducted by a claims analyst or clinician?
c. How can a reasonable and necessary claim denial be made without clinical review, in the absence of review of medical records or physician documentation?
d. It does not appear these claims are being medically reviewed except at the appeals level. There has been no probe reviews conducted to establish an error rate, no pre-pay review conducted to address an error rate, and no provider outreach and education being performed to address an error. At this time it appears no formal error rate has been established, published, or communicated from the DME MAC. Are any of these activities being scheduled for the future?
e. To date there is no Final coverage decision (NCD or LCD) issued regarding electrotherapy of the knee for osteoarthritis. Claims for Bionicare have been paid through out all Jurisdictions, J-D included, for over 3 years. Please address the reasons for category denial at this time without clinical review having been performed, POE having been conducted, without a Final Coverage Decision having been issued, and having such claims paid for in the past? (85% (+) of these claims are being overturned at the ALJ level.)
14. The KX modifier requirement appears in many LCDs but not all LCDs. In the TENS LCD there is a requirement for this modifier for the E0731 – TENS device only but not the Garment.
a. If the KX modifier is left off of a claim by error and the claim denied, is the claim eligible for a re-opening vs an appeal?
NAS Response: Yes, most items of DME for which a KX modifier was omitted in error can be corrected by calling phone reopenings or requesting a written reopening to add the KX modifier.
b. The KX modifier is not required by the LCD regarding a Garment for a TENS at this time. Nevertheless any medical review or audit requires the documentation be available upon request. Should a KX modifier accompany claims for Garments?
NAS Response: The policy actually states that a KX modifier should be used for the TENS garment only but does not address using a KX modifier for the other TENS HCPCS. This is because the other TENS purchases require a CMN to establish medical necessity, while the garment code does not. The policy specifically states the following in regards to the E0731 garment code:
“A claim for code E0731 must be accompanied by the brand name and model number of the conductive garment. Documentation supporting the medical necessity for the E0731 must be kept in the supplier’s files and be available upon request. If all the coverage criteria described in the Indications and Limitations of Coverage section have been met for E0731, a KX modifier must be added to the code.”
c. If we include a KX modifier on the claim for a Garment, (even though the LCD does not require it), will this have any impact on the claim being processed?
NAS Response: In general, adding a KX modifier when this is not addressed in the policy, will neither make the claim payable or denied. The KX modifier is just ignored during claims processing in this situation.
MEDICAL SUPPLIES and WOUND CARE
Leader: Robert Clock
Assistant Leader: Theresa Brammer
Executive Committee Contact: Sharon Nichelson
There are no questions at this time.
ORTHOTICS and PROSTHETICS (O&P)
Leader: JR Brandt
Assistant Leader: Janet Malinowski
Executive Committee Contact: Sharon Nichelson
Our O&P A Team questions for September 2008 are pertaining to a few codes that were in the knee policy effective July 1 2008.
15. In the new knee policy, L2770 has been deleted. This code however was being used and is still needed when fabricating a Subtalar control AFO (i.e., Arizona Type) when a nine inch device is medically necessary. Is there a suggested replacement code?
16 L2330 was also deleted in the new policy. Is there a recommended replacement code to use on the Subtalar control AFO?
17 L2820 per knee policy states that you must use a KX modifier when billing. We are asking what documentation is needed per medical policy for the L2820 code when using on an custom AFO or a off the shelf L1932 that is not included in the cost of the device and must be purchased separately for both cases and the Dr orders state the type of AFO and the soft interface for skin integrity, decreased pain and protection?
18. L2275 per knee policy, you must use KX modifier and we would like clarification on the medical policy/ documentation requirements when using with a Subtalar control AFO. The policy speaks about the usage with Knees.
NAS Response to 15-18: The DMDs discussed these four questions and agree that clarifications are needed here, especially for the Arizona AFO. There will be a forthcoming clarification on these issues
EDUCATION/COMMUNICATION/PCOM
Connie Lind-Fraher
Assistant Leader: Cindy Coy
Executive Committee Contact: Barb Stockert
19. Providers are allowed to use UPS and their electronic signatures for proof of delivery. Does this mean the provider can also use electronic signatures on deliveries made by their own delivery techs using a hand held device?
NAS Response: Yes, electronic signatures for proof of delivery are acceptable.
20. We are receiving a large number of suppliers that are finding their cross over / medigap claims not getting to the secondary payer source. This seems to be following the NPI implementation. Has there been an issue forwarding these claims and if so can you advise? (this question is also asked of CEDI).
NAS Response: See answer below in CEDI section.
21. Are there certain HCPCS odes that cannot be reopened if the KX modifier is forgotten in error on a claim?
NAS Response: Yes, certain HCPCS codes must always be submitted as an appeal, even if the error was forgetting to submit a KX modifier. This is because documentation is needed to support the appeal for these types of claims. Below are the situations that must always be requested as an appeal:
• Negative Pressure Wounds
• Surgical Dressings (number of units is over the policy amount)
• Wound Covers/Compression Stockings
• Parenteral and Enteral CMN/DIF issues
• Oxygen BIS
• Wheelchairs/Power Mobility Devices - HCPCS K0005 and higher
• Recoupment/Reduction of payment - Complete Refunds to Medicare Form
• Medicare Secondary Payer (MSP)-send inquiry to MSP Department
• Timely Denials
• Late Files
• Requests that require documentation
• ABN Issues
• GA/GY/GZ Modifiers
• Liability Issues
• Repairs to equipment
• Miscellaneous codes
This information was taken from the article titled “What Can and Cannot be Completed as a Reopening-Clarification” published on our web site on 9/18/08.
CEDI
Zena Jacobi Phone
Assistant Leader: Duane Ridenour
Executive Committee Contact: Troy Paz
22. Now that CEDI handles all the transmissions for the DMAC, does CEDI also coordinate / transmit the Secondary Claim information to other carriers for the DMAC. If not what roll is CEDI playing after the claims are processed? If yes there seems to be a large amount of crossover claims that are not even getting to the secondary payer. Can you advise or is there anything else we should be looking at?
23. We had been advised that CEDI will forward claims to all DMAC Regions and no other paperwork will be needed. We have hence found out that further applications may be required not only by CEDI but also the other DMAC’s. Can you clarify?
We had been advised that CEDI will forward claims to all DMAC Regions and no other paperwork will be needed. We have hence found out that further applications may be required not only by CEDI but also the other DMAC’s. Can you clarify?
Answer to Q23: All enrollment forms received by CEDI from suppliers and trading partners are processed by CEDI and the setups are completed in all four DME MACs.
Suppliers and trading partners previously setup for EDI by the DME MACs EDI departments, prior to the CEDI transition, will only be setup in the DME MAC Jurisdiction where they requested EDI enrollment.
(For example, if prior to CEDI, a supplier sent EDI enrollment forms to Jurisdiction B and C enrollment request was only processed and setup to allow electronic billing in Jurisdictions B and C.)
Suppliers who signed up for electronic transactions in one or more of the DME MACs prior to the CEDI transition and now are attempting to submit claims to a DME MAC where they did not previously enroll for EDI, will receive DME MAC error code 20011 on their electronic front-end report. To correct the front-end rejection error code of 20011, suppliers can either:
1. Submit an on-line EDI Enrollment Form to CEDI at . CEDI will then setup the supplier with the ability to send electronic transactions in all four DME MACs
2. Submit an Email to CEDI Enrollment using the following instructions:
▪ Send Email to: cedienrollment@
▪ Subject line should read: Edit 20011 Resolution
▪ Provide the following within the Email:
i. Submitter (Trading Partner) ID
ii. Submitter (Trading Partner) Name, Address, City, State, ZIP
iii. NSC/PTAN AND NPI numbers that received this error
iv. Contact Name
v. Contact Phone Number
Suppliers/Trading Partners who were assigned a Trading Partner/Submitter ID for electronic transactions by one or more of the DME MACs, prior to the CEDI transition and now are attempting to submit transactions to a DME MAC where they did not previously enroll for a Submitter ID, will receive error code 20004 on their electronic front-end report. To correct the front-end rejection error code of 20004, suppliers can either:
1. Submit the on-line Submitter Action Request Form to CEDI at . CEDI will setup the Trading Partner/Submitter ID with the ability to send and receive electronic transactions to all four DME MACs.
2. Submit an Email to CEDI Enrollment using the following instructions:
▪ Send an Email to: cedienrollment@
▪ Subject line should read: Edit 20004 Resolution
▪ Provide the following within the Email:
i. Submitter (Trading Partner) ID
ii. Submitter (Trading Partner) Name, Address, City, State, ZIP
iii. Contact Name
iv. Contact Phone Number
All CEDI enrollment forms can be found under the EDI Enrollment section of the CEDI Web site ().
NOTE: Requests submitted on-line with CEDI or through Email requests are processed in the same timeframe. Do not submit both forms and Email requests as this could delay processing the setup of your Trading Partner ID and/or supplier number.
Answer to Q22 & Q23 (as provided on the CEDI Vendor Conference Call on 8/20/08)
Issues with crossover and/or Medigap should be addressed with the DME MAC. The following is the process for the DME MAC and the COBC to determine claims that will go to the secondary payer. CEDI is not involved in claims processing, forwarding claims to the COBC, or any processing done by the COBC.
1. Claim is entered into the DME MAC system and begins processing.
2. The beneficiary information is cross referenced against the records at CWF.
3. If a match is found for the beneficiary with a COBC payer, the claim is marked to go to that payer via the COBC.
4. When the claim finalizes, it is delivered to the COBC by the DME MAC.
5. The COBC then translates the file from the DME MAC to be delivered to the secondary payer
6. The secondary payer has criteria for what claims they want to have delivered.
The claims criteria match occurs in Step 3 above at CWF where the beneficiary eligibility and claim selection criteria are read for a match. What sometimes occurs is a maintenance is performed by the COBC for a specific COBA (or secondary payer) ID, backdating effective dates and/or termination dates, and altering claim selection criteria. During the time between claim adjudication and receipt of the crossover claim, a file maintenance change results in the COBC denying the crossed claim as not meeting criteria.
If a claim fails to meet that criteria, it is produced on a report* that is sent to the supplier by the DME MAC contractor to let them know that although the claim stated it was sent to the secondary payer, it was not sent.
7. Claims that pass the criteria are delivered to the secondary payer with the supplier’s NPI.
8. If a supplier’s NPI is not on file with the secondary payer or cannot be successfully matched, the claim will not be processed.
*CEDI provided a sample of the report sent to the suppliers to those on the CEDI Vendor Conference Call distribution list. This report is sent to the supplier by the Medicare contractor (whether for Medicare Part A, Part B or DME and is not an EDI report or function.
24. We are receiving a large number of suppliers that are finding their cross over / medigap claims not getting to the secondary payer source. This seems to be following the NPI implementation. Has there been an issue forwarding these claims and if so can you advise?
NAS Response: In regards to Medigap crossovers, below are some reminders on claim requirements for crossovers from MLN Matters 5601, which was issued in October, 2007.
"Effective with claims filed to Medicare on October 1, 2007, all participating providers that have been granted a billing exception under the Administrative Simplification Compliance Act (ASCA) shall be required to enter CMS' newly assigned Coordination of Benefits Agreement (COBA) Medigap claim-based identifier (ID) within block 9-D of the incoming CMS-1500 claim for purposes of triggering Medigap claim-based crossovers. All other participating providers shall enter the newly assigned COBA Medigap claim-based ID, left-justified and followed by spaces within the NM109 portion of the 2330B loop of the incoming HIPAA ANSI X12-N 837 professional claim and within field 301-C1 of the T04 segment on incoming National
Council for Prescription Drug Programs (NCPDP) claims for purposes of triggering Medigap claim-based crossovers."
For more information on the crossover reports, reference MLN Matters 3709, published in the
Summer 2005, DMERC Dialogue, page 39.
Suppliers should also be aware that some additional editing for NPI for crossover claims recently went into effect. Below is the CEDI article on these changes:
COBA and Affiliated NPI Process Modifications
Effective October 6, 2008, Medicare will reject all incoming Medicare electronic claims that contain any legacy provider identifiers (qualifiers) other than the following:
• NPI (NM109 segment using the qualifier "XX")
• EIN/Federal Tax ID (using the qualifiers "EI" or "TJ" within the secondary provider REF loops)
• SSN (using the qualifier "SY" within the secondary provider REF loops)
The secondary provider REF loops in American National Standards Institute (ANSI) are: 2010AA, 2010AB, 2310A, 2310B, 2310C, 2310D, 2310E, 2330D, 2330E, 2330F, 2330G, 2330H, 2420A, 2420B, 2420C, 2420D, 2420E and 2420F. Medicare will not accept qualifiers other than "EI", "TJ" or "SY" in these secondary provider loops beginning with electronic claims accepted on or after October 6, 2008.
Note: The secondary provider REF loops listed above should only be used for Medicare claims when appropriate for the line of business submitted. The qualifiers ("EI", "TJ" and "SY") should only be used when valid for the loop submitted.
All loops and qualifiers referenced are part of the ANSI format. Providers and suppliers that have questions regarding these loops and/or qualifiers should contact their software vendor for further details.
Note: This article is written in reference to CMS Change Request 6024, Transmittal 1507, titled, "Coordination of Benefits Agreement (COBA) and Affiliate National Provider Identifier (NPI) Process Modifications."
NATIONAL SUPPLIER CLEARINGHOUSE (NSC)
Shelia Showalter-Roberson
Assistant Leader: Wade Hendrickson
Executive Committee Contact: Carlos Reyes
25 When completing a 855S form and entering the legal name of the company in section"__", what should a provider do if there is not enough room for the full legal name of the provider. We recently had a provider get rejected due to the fact they had to abbreviate/leave LLC off due to lack of room. .We wish to have a clean application go in and not tie up the provider or the NSC with resubmissions. This would apply to both electronic and paper submissions.
PDAC
Wade Hendrickson Phone
Assistant Leader:
Executive Committee Contact: John Kenny
There are no questions at this time.
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