WINTER 2020 DME MAC Jurisdiction C © 2020 Copyright, CGS Administrators, LLC. TWO VANTAGE WAY | NASHVILLE, TN 37228-1504 | CGSMEDICARE.COM DME MAC JURISDICTION C SUPPLIER MANUAL WINTER 2020 UPDATE We IMPACT lives. January 2020 Dear Supplier: The Winter 2020 version of the DME MAC Jurisdiction C Supplier Manual has been released. Please read the updated manual carefully. The DME MAC Jurisdiction C Supplier Manual is designed to provide vital, current DME MAC information. Supplier Manual updates are issued quarterly. Any new or revised material in this revision is shown in red text, while all text that has remained unchanged is shown in black text. Note that Web addresses/hyperlinks are an exception to this rule, as they are displayed in blue or teal. A summary of the changes is listed below. We strongly recommend using electronic copies of the Supplier Manual in order to ensure that you are using the most recent version. You can find the latest version of the Supplier Manual on our website at http://www.cgsmedicare.com/jc/pubs/supman/index.html. Please be sure to read the DME MAC Insider (the Jurisdiction C quarterly newsletter) for additional information. The DME MAC Insider is available on our website at http://www.cgsmedicare.com/jc/pubs/insider/index.html. Also visit the “News” page on the website for special notices concerning changes in regulations issued between publication releases. To receive automatic notification via email of the posting of policies, publications, and other important Medicare announcements, subscribe to the CGS email ListServ at http://www.cgsmedicare.com/medicare_dynamic/ls/001.asp. Supplier Manual Summary of Changes Revised chapters Pages containing changes Chapter 1 3, 5–7 Chapter 3 1, 3–5, 11, 21, 22, 33, 38 Chapter 4 3, 4 Chapter 5 24 Chapter 6 21 Chapter 7 2 Chapter 9 8, 11, 12, 18, 20 Chapter 13 5, 8, 16 1, 3, 34, 36, 38, 51, 56, 66, 69, 71, 72, 104, 106, 108, 142, 143, Appendix A 160, 201, 204, 211 © 2020, CGS Administrators, LLC CGS Administrators, LLC is a Medicare Part A, B, Home Health and Hospice, and DME Medicare Administrative Contractor for the Centers for Medicare & Medicaid Services. Table of Contents DME MAC Jurisdiction C Supplier Manual Table of Contents 1. Introduction 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 Winter 2020 DME MAC Jurisdiction C Supplier Manual Page 1 Table of Contents . Documentation in the Beneficiary’s Medical Record . Signature Requirements . Refills of DMEPOS Items Provided on a Recurring Basis . Beneficiary Authorization . Proof of Delivery (POD) . Advance Beneficiary Notice (ABN) . Amendments, Corrections, and Delayed Entries in Medical Documentation . Repair/Maintenance/Replacement . Delivery and Service Charges . Same/Similar Equipment and Advance Beneficiary Notices (ABN) . Pick-up Slips . Backup Equipment . Correct Coding . Miscellaneous HCPCS Codes . 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 Introduction . 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 Introduction . Mandatory Claim Filing . Assignment Agreement Winter 2020 DME MAC Jurisdiction C Supplier Manual Page 2 Table of Contents . 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 . 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 Introduction . Coordination of Benefits Agreement . Medigap 8. Electronic Data Interchange (EDI) Introduction . Benefits of EDI . ASCA . Transmitting Claims to Other DME MACs . Additional Electronic Options . Additional Information 9. Coverage and Medical Policy Introduction . DMEPOS Benefit Categories . Medical Review Program . Medical Policies . Advance Determination of Medicare Coverage (ADMC) for Wheelchairs . Condition of Payment Required Prior Authorization Program . Denial Categories 10. Pricing Introduction . Fee Schedules Winter 2020 DME MAC Jurisdiction C Supplier Manual Page 3 Table of Contents . Reasonable Charges . Drug Pricing . Single Payment Amount . Individual Consideration 11. Medicare Secondary Payer (MSP) Introduction . 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 Schedule . 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 Introduction . Unified Program integrity Contractors (UPICs) Winter 2020 DME MAC Jurisdiction C Supplier Manual Page 4 Table of Contents . Defining Fraud and Abuse . Procedures for Handling Fraud and Abuse Situations . Protect Yourself from Fraud . UPIC Contact Information 15. Resources Introduction . 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 . Claim0B Development Procedures . Medicare1B Summary Notice (MSN) . Medicare2B Remittance Notice (MRN) . Biller3B Purged Claim Report . ANSI4B Codes 18. Acronyms and Abbreviations Appendix A – Level II HCPCS Codes Winter 2020 DME MAC Jurisdiction C Supplier Manual Page 5 Introduction Chapter 1 Chapter 1 Contents Welcome 1. CGS’s Role as a DME MAC 2. What is Medicare? 3. What is DME? 4. Deductible and Coinsurance 5. Eligibility 6. Medicare ID— Health Insurance Claim Number (HICN) and Medicare Beneficiary Identifier (MBI) 7. The Medicare Card 8. Termination of Enrollment 9. Medicare Advantage Plans 10. Other Government Insurance Plans 11. Privacy Act of 1974 and HIPAA Privacy Rules 12. Freedom of Information Act (FOIA) Welcome Welcome to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction C Supplier Manual. This manual is provided for suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) who serve beneficiaries in Jurisdiction C. This manual contains an overview of important and useful information for DMEPOS suppliers regarding the Medicare program. It is the first resource that you should use for Medicare billing questions. The Supplier Manual is updated on a quarterly basis and is available on our website at https://www.cgsmedicare.com. In every quarterly Supplier Manual revision, all text that has been added or revised from the previous quarter’s version of the manual is shown in red text. All unchanged text is shown in black text. Please note that additions/revisions do not necessarily denote a change in policy. Some additions/revisions are added solely to provide greater clarity and understanding. To stay up-to-date on the most recent Medicare news, you should be sure to subscribe to our ListServ, the CGS electronic mailing list. ListServ gives you immediate access to the latest Medicare information, including: Medicare publications, important updates, educational workshops, and medical review information. To join the ListServ, visit our website at https://www.cgsmedicare.com. Internet-only Manual (IOM) References Most of the information in this manual is derived from the Centers for Medicare and Medicaid Services’ (CMS) Internet-only