Summary of Changes:
- Purpose: Update the denial liability for DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) claims that overlap inpatient hospital stays from patient responsibility to contractual obligation.
- Effective Date: July 1, 2024.
- Implementation Date: July 1, 2024.
Manual Instructions:
- There are no changes in the manual instructions for this CR.
Funding:
- This CR serves as technical direction for Medicare Administrative Contractors (MACs). Contractors should not incur costs beyond those allotted in their contracts without specific authorization.
General Information:
Background:
- Previous CR 8844 established an Informational Unsolicited Response (IUR) process for DME items provided during a Part A hospital inpatient stay, assigning liability to the patient.
- CR 7189 instructed contractors to assign liability to the provider when a CWF (Common Working File) reject was returned for DMEPOS provided during an inpatient stay.
- CR 13631 aims to align these instructions, assigning liability to the provider consistently, as payment for DMEPOS during inpatient stays is included in hospital reimbursement.
Policy:
- No changes in policy.
Business Requirements:
- Contractors must use specified remittance advice and MSN (Medicare Summary Notice) messages to deny claims for DMEPOS items provided during inpatient stays.
- Reason Code 97: Service included in payment/allowance for another service.
- Remark Code M2: Not paid separately when the patient is an inpatient.
- Group Code CO (Contractual Obligation)
- MSN 8.46: Payment included in allowance for another service.
- Contractors must adjust claims with incorrect liability when notified.
Provider Education:
- CMS will release national provider education content via the MLN Connects® newsletter. MACs should link this information on their websites and distribute it to providers.
Supporting Information:
- No additional recommendations or supporting information provided.
Contacts:
- Post-implementation contacts are the Contracting Officer’s Representatives (COR).
Funding for MACs:
- Contractors are to consider this as technical direction and notify the Contracting Officer if any part of the directive is outside the current scope of work.
