Updated: July 29, 2010
General Frequently Asked Questions (FAQs)
| Q1 | I need to find out if a beneficiary has had a specific item in the past (same or similar inquiry). What's the best way to find this information? |
| A1 | Information on same and similar equipment regarding capped rental
items and inexpensive or routinely purchased (IRP) items is available
through the IVR, at 1.866.238.9650. To access this information on the
IVR, choose option 2 for "Beneficiary Information" and then
option 3 for "CMN Status." You will need the following information
to utilize the IVR:
Provider Information
Beneficiary Information
The IVR will report the following information if there is same or similar equipment on file:
Note: CSRs are unable to release any extra information outside of what the IVR can provide. You are required to utilize the IVR for same and similar inquires unless you are inquiring on a same or similar item that does not require the DME MAC to set up a CMN/DIF (for example, diabetic shoes and inserts, as well as other items that are not capped rental or IRP items). Contact Customer Service at 1.866.270.4909 in this situation. For more information about the IVR and its abilities, please refer to the IVR Script and Flow Chart by clicking here. |
| Q2 | My claims are denying CO-150, remark code M3 – "Payer deems the information submitted does not support this level of service. Equipment is the same or similar to equipment already being used." What should I do? |
| A2 | The first thing to look for is whether or not the beneficiary has
or has had equipment that is same or similar to the equipment you are
billing and whether or not that equipment has met the reasonable useful
lifetime (five years for most DME). These denials typically must be
appealed through redeterminations. You may also choose to pick up your
equipment rather than pursue payment.
If the reasonable useful lifetime has not been met and the beneficiary still has the previous equipment, payment cannot be made. If the reasonable useful lifetime has not been met and the previous equipment was picked up by the original supplier, and there was a break in medical need greater than or equal to 60 days plus the days remaining in the last rental month, then you should file an appeal through redeterminations with documentation that supports the break in medical need. If the reasonable useful lifetime has not been met and the previous equipment was lost, stolen, or irrevocably damaged, then you should appeal through redeterminations with appropriate documentation (such as a police report). |
| Q3 | What would the next step be for a claim that denied because the beneficiary was in a Skilled Nursing Facility (SNF)? |
| A3 | If the beneficiary is enrolled in a covered Part A Stay, the SNF
and not the supplier would bill Part A. As a result, you would look
to the SNF for payment rather than the beneficiary or the DME MAC.
For more information regarding Skilled Nursing Facilities, including
a link to the Consolidated Billing List, as well as a list of the items
which are billable when the beneficiary is in a non-covered Part A
stay, please see the DME
MAC Jurisdiction C Supplier Manual, Chapter 6.
Also, SNF/inpatient hospital stay information is available on the DME MAC Jurisdiction C IVR. The SNF/inpatient hospital stay option provides:
To access the SNF/inpatient hospital stay option on the IVR, press option 2 (Beneficiary Information) from the main menu, then press 4 (SNF/Inpatient Hospital stay). |
| Q4 | How can I determine if a beneficiary is enrolled in a Medicare Advantage Plan (MAP)? |
| A4 | MAP data can be retrieved through the IVR by calling 1.866.238.9650. To access the MAP information on the IVR, press option 2 (Beneficiary Information) from the main menu, then option 1 (Beneficiary Eligibility). After following the prompts, the IVR will report the effective dates of the MAP enrollment, the name of the MAP (if available), and the contract ID (usually one letter and four numbers). A list of names, addresses, and phone numbers for MAP contractors can be found on the CMS website. |
| Q5 | I am receiving a CO-176 denial (payment is denied because prescription is not current). Why? |
| A5 | This type of denial is generally a result of billing outside of the
end date on a CMN/DIF, which could be 13 or 15 months (the end of the
capped rental period). The following is an example of this situation:
A beneficiary has a K0001 on file with an initial date of January 1, 2008. The 13th month of rental would normally be billed for January 1, 2009; however, one month during the rental period denied because the beneficiary was in a Skilled Nursing Facility (SNF). As payment will not be made for the month the beneficiary was in the SNF, the 13th month for the capped rental period would have to come in February 2009. The claim for February would deny as CO-176 unless there is a claim narrative asking to extend the rental period for the remainder of the rental months. The narrative request to extend the rental period would also be needed if the item was originally provided by another supplier and there is no justification to start a new capped rental period. If the item was originally provided by another supplier and you believe a new capped rental is warranted, resubmit the claim with a narrative documenting why a new capped rental should begin. |
| Q6 | When billing a claim for an oxygen rental, I am getting a CO-35 or CO-A1 denial with remark code N370 – "Lifetime benefit maximum has been reached. Billing exceeds the rental months covered/approved by the payer." Why? |
| A6 | Beginning January 1, 2006, oxygen equipment rentals will cap after
36 months have been paid. For beneficiaries who received the equipment
prior to 2006, the 36-month total will begin to accumulate beginning
with the first claim on or after 1/1/2006.
If you believe you received this denial in error and that not all 36 rental months have been paid, call our Customer Service line at 1.866.270.4909 to have a Customer Service Representative research the issue. In cases where you have received this denial when billing for replacement oxygen at the beneficiary's discretion due to the reasonable useful lifetime being met, it is possible one or more required elements were missing to process your claim correctly. For replacement oxygen, the following elements should be on your first month's claim:
For more information regarding oxygen and oxygen equipment please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 5. |
| Q7 | I called the IVR to check claim status and it says there is nothing on file for the date that I entered or that the claim that I submitted is not there. I haven't received anything telling me my electronic claim was rejected. What do I do? |
| A7 | First, make sure the supplier information (NPI, PTAN, TIN) you are using is the same on the claim that you are checking status on. The IVR will only give claim status for the NPI/PTAN/TIN you entered at the start of the call. If this is not the issue, try resubmitting the claim. If your sources are saying the claim transmitted correctly, but the IVR still is not showing the claim on file, contact the Common Electronic Data Interchange (CEDI) at 1.866.311.9184. If you are receiving a rejection report regarding claim content, contact our Customer Service Line at 1.866.270.4909. |
| Q8 | How do I fix a claim that denied CO-176 with remark code
M60 – "Payment denied because the prescription is not
current," when billing a claim for oxygen equipment? |
| A8 | This denial is usually due to a missing recertification CMN on file. For group one oxygen patients, a recert CMN is due 12 months after the initial date. For group 2 oxygen patients, a recert CMN is due three months after the initial date. If there is previous oxygen equipment on file, and there was a break in service due to a change in medical need greater than 60 days plus the days remaining in the last rental month, then resubmit your claim with your initial CMN and include the break in service information in the claim narrative. Otherwise, a recert CMN will be needed in order to continue payment for oxygen. |
| Q9 | What are my possible next steps with a medical necessity denial (CO-50, remark code N115) based on a Local Coverage Determination (LCD)? |
| A9 | Try following these suggestions:
If the item requires a KX modifier per the LCD, you will need to file an appeal through Redeterminations in order to add, change, or remove the KX modifier. The same rule applies to the GA, GZ, and GY modifiers. For additional information regarding these modifiers, please refer to the Archived News Section of our website for the July 30, 2009 article entitled: IMPORTANT CHANGE - KX, GA, GZ and GY Modifiers - Claim Rejection as well as an October 29, 2009 and December 2, 2009 article entitled: Reopening Requests for Modifiers KX, GA, GZ and GY. Note: You cannot resubmit a medical necessity denial. It must either be adjusted through Reopenings (if a clerical error or minor omission) or appealed through Redeterminations. |
| Q10 | Explain how we should approach billing for a beneficiary that regularly moves from one state to another (a "snowbird") or has recently moved to another jurisdiction. |
| A10 | Claims should be submitted to the jurisdiction in which the beneficiary
resides at the time of the claim's submission regardless of where they
lived on the date of service. For example: From 11/1/08 through 4/31/09
a beneficiary resided in Jurisdiction C and received a walker on date
of service 1/1/09. Beginning 5/1/09 to current, the beneficiary is
residing in Jurisdiction A. If the suppler submits their claim prior
to 5/1/09, then the claim should be filed to Jurisdiction C. If the
supplier waits to submit their claim until after 5/1/09, then the claim
should be filled to Jurisdiction A, despite the fact they were in Jurisdiction
C when they received the walker.
If you believe you received a CO-109 denial ("Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor") in error, contact our Customer Service Line at 1.866.270.4909. If the address on file is incorrect, the beneficiary will need to contact Social Security Administration to have their file updated. If the beneficiary's file has been updated to reflect a Jurisdiction C address, then just resubmit your claim. Note: Other issues that could cause a CO-109 denial are HMO enrollment or billing a HCPCS code that would be covered by a different carrier (i.e. local Part B carrier). |
| Q11 | My claim denied CO-58 (Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service). The beneficiary received the equipment in our office. Did this deny in error? |
| A11 | No. Place of service (POS) 11 – Office is not a valid POS for
DMEPOS items. For claims submitted to the DME MAC, the place of service
is considered to be the place where the beneficiary will primarily
use the DMEPOS item. The following is a list of valid POS codes for
submission to the DME MAC:
01 Pharmacy Coverage consideration for DMEPOS items in a Skilled Nursing Facility (31), unless the beneficiary is in a covered Part A stay, or a Nursing Facility (32) is also considered for certain types of equipment. Please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 6, for a complete list of these items, as well as additional information regarding place of service. |
| Q12 | Why would my claim deny CO-16 (Remark code MA114, claim service lacks information which is needed for adjudication. Missing/incomplete/invalid information on where the services were furnished)? |
| A12 | This denial may be related to the information on the claim regarding
the facility where the beneficiary is located. For example, if the
place of service is 31 – Skilled Nursing Facility (SNF), then
block 32 of the CMS-1500 Health Insurance Claim Form would need to
contain that SNF's name and address. Likewise, block 32a would need
to contain that SNF's NPI number. In a case where block 32 is blank
or 32a contains an invalid NPI, and the place of service on the claim
is 31, the claim would deny. If the place of service was incorrectly
filled out, then resubmit the claim with the correct place of service.
Note: This type of denial cannot be corrected through Reopenings or Appeals. If you have found that you billed incorrectly and received this denial, you must resubmit the claim with the correct information in order for it to process correctly. |
| Q13 | What should I include when writing to Written Correspondence? |
| A13 | It is important to include any information pertinent to your inquiry, including your NPI, PTAN, last five digits of your TIN, and supplier name (or send your inquiry on official company letterhead), and, if appropriate, the beneficiary's name and HICN. This will allow us to respond more specifically to your inquiry. Please also include your name and phone number. For more information regarding written inquiries, as well as inquires in general, please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 13. |
| Q14 | Why does my claim say CO-45 (Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement) even though the claim paid? |
| A14 | When you have a paid claim and there is an ANSI denial reason C0-45, it generally means that your submitted amount was higher than the Medicare allowable for the item you billed. Medicare will only reimburse at the appropriate fee schedule amount. Current and past fee schedule amounts can be obtained by going to the DME MAC Jurisdiction C web page (www.cignagovernmentservices.com/jc) and clicking on Fee Schedules in the Coverage and Pricing section. |
| Q15 | Who would be an authorized representative for filling out the Electronic Funds Transfer (EFT) Authorization Agreement form? |
| A15 | An authorized representative is an appointed official of the entity (including, but not limited to, officer, director, manager, general partner, etc.) who has been given the legal authority by the entity to enroll it in the Medicare DMEPOS supplier program, to make changes and/or updates to the entities status in the DMEPOS program, and to commit the entity to fully abide by the laws, rules, and regulations of the Medicare DMEPOS program. A written appointment or delegation of authority is required to be on file with the National Supplier Clearinghouse (NSC) for anyone other than officers of the company and general partners. The person(s) granted the authority of authorized representative must sign the appointment as well to ensure that their signature is on file with the NSC. For more information regarding EFT, please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 6. |
| Q16 | What is the time limit for filing a claim? What are my options when I receive a CO-29 (the time limit for filing has expired) denial? |
| A16 | As a result of the Patient Protection and Affordable Care Act (PPACA), Section 6404, claims with dates of service on or after January 1, 2010, received later than one calendar year beyond the date of service will be denied by Medicare for past timely filing. For example: if your claim has a date of service on March 21, 2010, the claim must be filed by March 20, 2011. Claims with dates of service prior to October 1, 2009, will be subject to pre-PPACA timely rules and edits (see the timely filing chart in the DME MAC Jurisdiction C Supplier Manual, Chapter 6). Claims with dates of service October 1, 2009 through December 31, 2009 must be received by December 31, 2010. For more information about timely filing related to PPACA, please refer to the MLN Matters Article MM6960 . If you have received a denial for past timely filing, you may bill the beneficiary for 20% of the allowed amount; however, you will not receive payment for the other 80%. If you feel you can show good cause for filing late, you may submit a request to reopenings. |
| Q17 | When should I submit a written reopening request versus a telephone reopening request? |
| A17 | Telephone reopenings are available to handle resolution of minor
errors or omissions involving:
If your issue does not involve one of the above scenarios, you should send your reopening request in writing. For more information regarding reopenings please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 13. |
| Q18 | What claim documentation should be submitted when billing for a Continuous Passive Motion (CPM) device (E0935)? |
| A18 | The following information should be included in the claim narrative
when billing for an E0935:
Leaving out any of these elements could result in a medical necessity denial. |
| Q19 | Is there a place I can go, other than the IVR, to check claim status? |
| A19 | Yes. CSI/BE is available for suppliers to check claim status and beneficiary eligibility electronically. For more information on CSI/BE, click here. |
| Q20 | How would I appeal a Medical Necessity (CO-50) denial? |
| A20 | First fill out a Redetermination Request Form. You can find the form
by accessing the Forms
section of our website. Once the form is completed, you may send
it and any documentation supporting payment for your claim to the following
address:
CIGNA Government Services You may also now fax redetermination requests. The fax number for a redetermination request is 1.615.782.4630. For more information regarding appeals, please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 13. |
| Q21 | When should I bill with a KH modifier rather than KI or KJ? |
| A21 | KH, KI, and KJ are modifiers used with capped rental items and PEN
pumps. These modifiers signify which month of the rental is being billed.
KH is used only for the first month of rental. KI signifies the second
and third months. KJ represents the fourth month through the end of
the rental period. It is important that you use these "K" modifiers
correctly.
Additionally, if the capped rental item was previously provided to a Medicare beneficiary and a new rental period is now being requested, you must add a narrative to the first month's claim that clearly explains why the item is being replaced (in addition to using the KH modifier) to avoid unnecessary denials. We recommend that you use our Interactive Voice Response (IVR) system at 1.866.238.9650 to verify if equipment was previously provided. CIGNA Government Services offers an online Modifier Finder Tool which can assist you in determining the correct usage of these (and other) modifiers. Beginning on August 10, 2009, CIGNA Government Services will no longer provide corrections to "K" modifiers when they are billed incorrectly. These claims will deny with ANSI reason code 182, remark code N56. If you receive a denial due to either the incorrect billing of the "K" modifier or a missing narrative, you must correct the information and resubmit the claim. |
| Q22 | I am receiving an increased number of claims denying for primary insurance, what information should I transmit with the electronic file since I am not allowed to submit a hardcopy of the primary EOB? |
| A22 | When submitting payment information from a primary insurer it is necessary to include the amount billed to the primary; primary adjustment amount; primary approved amount; primary paid amount; and patient responsibility/contractual obligation, including the appropriate CARC code. The appropriate Claim Adjustment Reason Code (CARC) should be used to explain the reason for the adjustment. A complete list of these codes can be found at http://www.wpc-edi.com. Please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 11 for additional information. |
| Q23 | What type of CMN should I submit to subsequently add portable oxygen to an existing concentrator? |
| A23 | A revised CMN is required to subsequently add portable oxygen to an existing concentrator. Specific instructions are available in the Oxygen LCD and in Chapter 4 of the Supplier Manual. Please note that if the concentrator was qualified based on a sleep test, a new qualifying test taken at rest or during exercise must be performed in order for the portable to be covered. |
| Q24 | I received a denial indicating that documentation requested was not received by Medicare and I do not see that I received a request for additional documentation; what should I do? |
| A24 | It is the responsibility of the supplier to maintain medical necessity
documentation, as outlined in the documentation sections of the Local
Coverage Determinations (LCD) and documentation chapters (chapters
3 and 4) of the Jurisdiction C DME MAC Supplier Manual. Whenever
a claim denies for lack of documentation, it is necessary to request
a redetermination with the supporting documentation within 120 days
of the original denial for payment consideration.
To request a redetermination, please utilize the DME MAC Jurisdiction C Redetermination Request Form found on the DME MAC Forms Page. |
| Q25 | I received a denial with ANSI Reason Code 172 and I am not sure why my claims are denying this way, how do I correct these? |
| A25 | ANSI Reason Code 172 occurs when the appropriate certification and/or licensure is not on file with the National Supplier Clearinghouse (NSC). To get the records corrected, suppliers shall obtain the necessary certifications and submit to the NSC for processing. If the certification is already on file with the NSC, contact CIGNA Government Services Customer Service for assistance at 866.270.4909. |
| Q26 | I received a denial with ANSI Reason Code 151 and Remark Code N362. What causes this denial? |
| A26 | This denial indicates that the number of items provided exceed the
acceptable maximum. This denial is related to Medically Unlikely Edits
(MUEs). The CMS developed Medically Unlikely Edits (MUEs) to reduce
the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT
code is the maximum units of service that a provider would report under
most circumstances for a single beneficiary on a single date of service.
MUEs are confidential and are for CMS and CMS Contractors' use only;
therefore, MUE values for specific HCPCS codes cannot be released since
CMS does not publish MUEs. Information about MUEs is found at: http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp
When this denial is received, it is necessary to submit a redetermination with medical documentation supporting the necessity of the items. To request a redetermination, please utilize the DME MAC Jurisdiction C Redetermination Request Form found on the DME MAC Forms Page. |
| Q27 | When do I use the KE modifier? |
| A27 | The KE modifier is meant to be used for supplies and accessories that can be used with both competitively bid and non-competitively bid items. You must only attach the KE modifier when the supply or accessory is being used with a non-competitively bid item. For example, HCPCS code E0981 (Wheelchair Accessory, Seat Upholstery, Replacement Only, Each) can be used with both competitively bid standard and complex rehabilitative power wheelchairs (K0813 thru K0829 and K0835 thru K0864), as well as with non-competitively bid manual wheelchairs (K0001 thru K0009) or a miscellaneous power wheelchair (K0898). If billing the E0981 for use with a K0001 (non-competitively bid), then the KE modifier should be appended to the code. If billing the E0981 for use with a K0823 (competitively bid), the KE modifier would not be used. Please see MLN Matters Number MM6270 for more information regarding the KE modifier. |
| Q28 | Where can I find instructions on using the Interactive Voice Response (IVR) system? |
| A28 | Links to resources on the IVR can be found on the DME MAC Jurisdiction C Contact Information web page. Go to www.cignagovernmentservices.com and click on DME MAC Jurisdiction C, and then Contact Information in the lower left hand section labeled Site Help and Contact Information. These resources include an IVR Script, which details each feature of the IVR and explain how to correctly input information, and also an IVR Flow Chart, which diagrams in a quick reference format the options and information that are available. |
| Q29 | Where can I find phone numbers and addresses for CIGNA Government Services and other Medicare Contractors? |
| A29 | Addresses and phone numbers for Jurisdiction C can be found on the Contact
Information page on our website located in the Site Help and
Contact Information section.
You can also find contact information for other DME MACs as well as other Jurisdiction C resources by referring to the DME MAC Jurisdiction C Supplier Manual, Chapter 15. For a complete list of all Provider Call Center Toll-Free numbers, you may visit The Centers for Medicare and Medicaid Services (CMS) website at: www.cms.hhs.gov, click on the MLN Products link in the Top 10 Links section, and click on the Provider Call Center Toll Free Numbers Directory link to download the file. |
| Q30 | Where can I find guidance on filling a claim? |
| A30 | Information on filling claims can be found in the DME MAC Jurisdiction C Supplier Manual. Refer to Chapter 6 for help with paper claims and Chapter 8 for information on electronic claim submission. |
| Q31 | Where should a beneficiary inquire on issues regarding their claims? |
| A31 | All beneficiary inquiries should be handled through the Beneficiary Contact Center. Beneficiaries can contact 1.800.Medicare to receive assistance with their claims. |
| Q32 | Where can I find information on overpayments and refunds? Where can I get information related to a specific offset? |
| A32 | Information regarding overpayments and refunds can be found in the DME
MAC Jurisdiction C Supplier Manual, Chapter 12.
For information regarding a specific offset, contact our Interactive Voice Response (IVR) system. Press option 3 for Payment Information and 3 again for Offset Information. The IVR will ask you for your NPI, PTAN, last 5 of your TIN, and the FCN from your Remittance Advice. The IVR will provide you with the claim details of the original overpayment as well as the overpayment letter date and current offset balance. |
| Q33 | How can I order a paper copy of the DME MAC Jurisdiction C Supplier Manual and other publications from CIGNA Government Services? |
| A33 | To order paper copies of publications from CIGNA Government Services,
you will need to fill out the DME MAC Jurisdiction C Publication Order
Form. The form can be found on our website in the Forms section.
There is a charge for this service.
It should be noted that all DME MAC Jurisdiction C publications are available free online. |
| Q34 | Where can I find coverage criteria for a specific HCPCS code or item? |
| A34 | Refer to the appropriate Local Coverage Determination (LCD) or Policy Article for information on the coverage criteria for that code or item as well as documentation requirements. A link to the Jurisdiction C LCDs and Policy Articles can be found in the Coverage and Pricing section of our website. |
| Q35 | Where can I find information on workshops and other education opportunities? |
| A35 | Information on workshops, as well as many other educational opportunities, are made available by our Provider Outreach and Education (POE) team and can be found in the Education section of our website. There you will find dates and sign-up information for Workshops, Seminars, Webinars, and various other educational opportunities and materials. Additionally, if you haven't already, we would recommend that you sign up for our ListServ. By joining the CIGNA Government Services electronic mailing list, you can get immediate updates on all Medicare information, including: Medicare publications, important updates, workshops, and medical review information. To join, click here and fill in the appropriate information. |
| Q36 | Where can I find information on how to fill out the CMS-1500 Health Insurance Claim Form? |
| A36 | Instructions on filling out the CMS-1500 form, as well as descriptions of each block of the form, can be found in the DME MAC Jurisdiction C Supplier Manual, Chapter 6. The Supplier Manual will walk you through each block of the form and indicate what information is required in order to correctly process your claim. |
| Q37 | My claim has denied with ANSI reason code 96 (Non-covered charge[s]) with remark code M124 (Missing indication of whether the patient owns the equipment that requires the part or supply). What can I do to fix this? |
|---|---|
| A37 | This denial is the result of billing a HCPCS code that does not have the required corresponding base equipment on file with Medicare.
Call our Interactive Voice Response (IVR) at 1.866.238.9650 prior to submitting your claim to ensure the necessarily base equipment is on file for the item or accessory you are billing. For information on equipment that does not require the DME MAC to set up a CMN/DIF to keep track of payments (for example, diabetic shoes, refractive lenses, or other items that are not capped rental or IRP items) contact our Customer Service line at 1.866.270.4909 for assistance. |
| Q38 | Explain a CO-18 (Duplicate claim/service) denial with remark code N111 (No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated). |
| A38 | This generally means that we have previously processed (paid, denied, or reduced) a claim for the same HCPCS code and date of service you submitted. Call the Interactive Voice Response (IVR) system to receive the original claim decision information. If the claim paid, then the duplicate denial is accurate. If the original claim denied, use the original denial to establish your next step and appeal time limits. If you believe a claim denied as a duplicate in error, please contact our Customer Service line at 1.866.270.4909 for assistance. |
| Q39 | Where can I find information on the appeals process? |
| A39 | Information regarding the appeals process, rights, and contact information can be found in the DME MAC Jurisdiction C Supplier Manual, Chapter 13. |
| Q40 | How can I order a copy of a Remittance Advice (RA)? |
| A40 | To order a duplicate RA, call our Interactive Voice Response (IVR) system at 1.866.238.9650. Press option 1 for Claims Information, then option 4 to order a duplicate RA. You will need the following information:
If you do not know the payment date, you may also order a duplicate remittance advice through the claim status option on the IVR. Press option 1 and option 1 again to check claim status. After the IVR gives you information on the processed claim, it will ask you if you want to order a duplicate remittance advice for your claim. To order a duplicate RA via this method, you will need the following information:
|
| Q41 | How do I correct a CO-4 denial (the procedure code is inconsistent with the modifier used, or a required modifier is missing)? How do I determine what the cause is? |
| A41 | There are several possible causes for a CO-4 denial. Use the information below to assist in determining the issue and submit a corrected claim.
|
| Q42 | I received a development letter and sent in my documentation. Now I am receiving a CO-176 denial with a remark code of N115. What does that mean and how do I fix it? |
| A42 | Generally, a CO-176 denial (prescription is not current) with a remark code of N115 means that upon medical review of the submitted documentation, the physician’s order/prescription was either missing or invalid. Review your documentation and submit a redetermination request. Remember to include all pertinent information required to submit an appeal, including each piece of documentation that was requested in the development letter that you previously received. |
| Q43 | I am attaching a CMN electronically but am still receiving a CO-173 (service was not prescribed by a physician) with remark code M60 (missing Certificate of Medical Necessity). How do I get this issue resolved? |
| A43 | It may be necessary to contact your software vendor or the Common Electronic Data Interchange (CEDI) contractor in order to determine why your CMN is not transmitting electronically. The CEDI contractor may be reached at 866.311.9184 Monday through Friday from 9:00 AM to 7:00 PM Eastern Time. You may also request a written reopening for your claim and include a copy of the CMN; however it is important that any electronic billing issues are resolved as soon as possible to ensure accurate processing of your Medicare claims. If you have received a CO-173 denial with remark code M60, but your CMN is now on file, you can simply resubmit your claim. Use our Interactive Voice Response (IVR) unit to determine if the appropriate CMN is on file by calling 1-800-238-9650 and selecting option 2, followed by option 3. |
| Q44 | My patient received their capped rental DME prior to January 1, 2006 , so we have been billing maintenance and servicing (MS) every six months since the equipment capped at 15 rental months. We were just paid for the last MS claim two months ago and the patient is now electing to receive new equipment and has an order from his/her physician. The reasonable useful lifetime has been met. Do we have to wait the remaining four months of the MS period prior to delivering new equipment? |
| A44 | No, if the same supplier that delivered the original equipment is delivering the replacement, they may deliver at any time regardless of when the last MS payment was made, so long as the beneficiary elects to receive new equipment and they have a new order from the physician. When billing for the new equipment, please include the RA modifier and a narrative on the claim explaining the situation. |
| Q45 | What is PECOS and how does it affect me as a DMEPOS supplier? |
| A45 | In an effort to ensure that the referring/ordering physician on a DMEPOS claim has a current enrollment record in Medicare and is of a specialty that is eligible to order and refer, all physicians that order/refer DMEPOS items must have updated enrollment information in the Provider Enrollment, Chain and Ownership System (PECOS). This requirement is being implemented in two phases:
If you are receiving a warning on your CEDI GenResponse Report that the ordering/referring physician is not enrolled in PECOS, beginning January 3, 2011 your claims containing that physician’s NPI will reject unless the physician updates his/her enrollment information in PECOS. Contact the physician to inform him/her of the warning you are receiving so they may take the appropriate action to get the issue resolved. The DME MAC Jurisdiction C Medical Director has written a letter for suppliers to assist them in informing the physician of what needs to be done and how to do it. This letter may be found in the Forms section of our website. Additionally, CMS has made available a file that contains the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain an NPI). This file is downloadable from the Medicare provider/supplier enrollment website at www.cms.hhs.gov/MedicareProviderSupEnroll. After accessing the link, click on "Ordering/Referring Report" on the left-hand side. |
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