reimbursement@wiki

CMS -- DME MAC page

DME definition [42 CFR 414.202]

• Durable medical equipment means equipment, furnished by a supplier or a home health agency that—
• 1. Can withstand repeated use;
  2. Is primarily and customarily used to serve a medical purpose;
  3. Generally is not useful to an individual in the absence of an illness or injury; and
  4. Is appropriate for use in the home.

DME Payment and Pricing

• Overview of  Payment for DME
• • DME Payment System Basics, MedPAC (October 2008)
  • Class III Medical Devices Do Not Warrant a Distinct Payment Amount Update, GAO-06-62 (2006)
  • • Good explanation of base-year deflation/inflation on pp.9-10
• Pricing and Gap-Filling DMEPOS Fees. "Gap filling" refers to a process carriers use to calculate payments for specific items that are not listed on a fee schedule and which have no charge data for 1986-1987, the base year for most DMEPOS payment amounts.  In short, the process involves calculating a new 1986-1987 base period by deflating current prices to approximate the base year price and then reinflating those amounts by any allowable inflation update."
• • Medicare Claims Processing Manual, Chapter 23 (Fee Scheduling Administration and Coding Requirements), Section 60.3
• • Noridian DME Supplier Manual, Chapter 12 (good overview of DMEPOS payment methodologies and gap filling)
• • NHIC DME Supplier Manual, Chapter 6 - Pricing, p.6-4
• DMEPOS Fee Schedule

PDAC

Noridian Administrative Services, LLC (NAS) serves as the Pricing, Data Analysis and Coding (PDAC) Contractor, performing the following activities that Palmetto GBA's Statistical Analysis DME Regional Carrier (SADMERC) performed prior to August 2008:

• Provide data analysis support to the DME Program Safeguard Contractors (PSCs)
• HCPCS Review -- Guide manufacturers and suppliers on the proper use of the Healthcare Common Procedure Coding System (HCPCS) through product reviews and decisions
• Conduct national pricing functions for DMEPOS services
• DME Coding System -- Assist CMS with DMEPOS fee schedules
• NCD/HCPCS Crossswalk
• Oral Anti-Cancer Drug Updates

 

DME Info

• LMN and DME Info Forms (DIFs) for claims processing - Transmittal 198

DMEPOS Competitive Bidding Program (CBP)

DMERC Reorganization

DMERCs reorganized into two contracted organizations:

• Medicare Affiliated Contractor (MAC)
• • MAC will manage the regions billing, customer service and other day-to-day operations.
  • Effective March 1, 2008, the LCD workload is transitioning from the DME PSCs to the DME MACs (per CMS Transmittal 253).
• Program Safeguard Contractor (PSC)
• • PSC will be responsible for benefit integrity, medical reviews, and medical policy.
  • Effective March 1, 2008, the LCD workload is transitioning from the DME PSCs to the DME MACs (per CMS Transmittal 253).

 

Region A

• MAC - National Heritage Insurance Company (replacing HealthNow)
• PSC - TriCenturion; Dr. Paul Hughes will serve as the medical director.
• States included: Connecticut, Delaware, the District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont

Region B

• MAC - National Government Services (merger of AdminaStar Federal, Anthem Health Plans of New Hampshire, Inc., Associated Hospital Service, Empire Medicare Services, United Government Services)
• PSC - TriCenturion; Dr. Paul Hughes will serve as the medical director.
• States included: Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin
• Fee Schedules and Pricing

Region C

• MAC - CIGNA Government Services
• PSC - TrustSolutions; Dr. Oleck will serve as the medical director.
• States included: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia and West Virginia
• 2007 DMEPOS Fee Schedule

Region D

• MAC - Noridian Administrative Services(replacing Cigna)
• PSC - EDS (& IntegriGard - medical review functions only); Dr. Mark Pilley will serve as the medical director.
• States included: Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington and Wyoming
• 2007 DMEPOS Fee Schedule

Archived SADMERC Material

• SADMERC (Palmetto GBA)
• DMECS (DME Coding System) + National DME Fee Schedule

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