From

Jurisdiction B

February 14, 2013

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/ / Portable Oxygen Notification of Prepayment Review
National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) will be initiating a widespread prepayment medical review of random claims for portable oxygen (E0431) and oxygen related equipment. Data analysis has identified this area as a top CERT error.
If you are randomly selected for a prepayment medical review you will receive an additional documentation request (ADR) letter requesting the following information:
  • A copy of the most recent Certificate of Medical Necessity (CMN) prior to the date of service
  • The treating physician's detailed written order for the DMEPOS item (CMN can serve as the detailed written order if sufficiently completed)
  • Proof of a dispensing order must be submitted if the date of service is prior to the signature date on the detailed written order
  • Copy of the beneficiary's most recent arterial blood gas PO2 and/or oxygen saturation test value as reported on the CMN
  • Medical documentation supporting that the beneficiary is mobile in the home
  • Proof of delivery (including beneficiary name, date, item(s) delivered and signature of person receiving the items)
  • Medical records supporting a diagnosis of the disease requiring home use of oxygen, the oxygen flow rate, and estimate of the frequency or duration of use, and the duration of need
  • Medical records confirming continued medical need if subsequent claims were billed
  • Documentation of a physician's office visit prior to the initial date of service: The physician's office visit needs to be within 30 days of the initial CMN date, 90 days prior to the recertification CMN date.
  • A copy of any mandatory Advance Beneficiary Notice (ABN) of non-coverage to the beneficiary
If the requested documentation is not provided within the time frame indicated on the ADR letter, the claim will be denied with an American National Standards Institute (ANSI) CO-50 and N102 denial because documentation was not received. If the supplier subsequently submits a request for appeal with the requested documentation within 120 days of the date of receipt of the initial determination the request will be treated as a reopening and not a redetermination. If the claim reopening is unfavorable to the supplier or if you do not agree with the reopening you still have appeal rights on the claim and may submit a redetermination request.
Suppliers must comply with the documentation requirements as outlined in the Local Coverage Determination (LCD) and Policy Article (PA) for Oxygen and Oxygen Equipment. Suppliers can refer to the LCD and PA for Oxygen and Oxygen Equipment on the National Government Services Web site at:

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