**In July the CBIC shared information from CMS on obtaining written orders for Competitive Bidding Items. This information was not distributed by the MAC’s so the Executive Committee has brought it to the attention of Cindy at Noridian for clarification.
Grace Period for Obtaining Written Orders for All Competitive Bidding Items
The Centers for Medicare & Medicaid Services (CMS) will allow a grace period of 120 days (that is, through October 31, 2016) for contract suppliers to obtain written orders for all competitive bidding items for beneficiaries who reside in a Round 2 Recompete competitive bidding area (CBA) and have transitioned to them from a non-contract supplier beginning July 1, 2016. For a listing of zip codes included in the Round 2 Recompete, visit This grace period:
1. Is provided to give contract suppliers additional time to obtain the required written orders for the large volume of beneficiaries transitioning to them from non-contract suppliers at the start of Round 2 Recompete of the DMEPOS Competitive Bidding Program; and,
2. Does not apply to new patients who are obtaining the items for the first time or who reside in an area not included in a Round 2 Recompete CBA.
Once the 120 day grace period expires, beginning November 1, 2016, contract suppliers will be expected to submit the required documentation upon request without exception. Absent such documentation, CMS contractors shall collect overpayments following established procedures. In cases where a previous supplier does not provide the required documentation to the new [contract] supplier, or in other circumstances where documentation is not available, beneficiaries will need to visit their physician in order to obtain a new order to fulfill this requirement and other supporting documentation as appropriate.
Replacement of Accessories used with a Beneficiary-Owned CPAP Device or RAD Purchased by Medicare
In the case when replacement of essential accessories is used with beneficiary-owned CPAP device or RAD equipment purchased by Medicare following 13 months of continuous use, the medical necessity for the beneficiary-owned base CPAP device or RAD is assumed to have been established. Therefore, to make a payment determination, contractors shall only review: (1) the base DME item continued use and continued medical need requirements; and (2) the medical necessity of the replacement of specific accessories or furnishing of new accessories and whether they are essential for the effective use of the base DME.
The contractor shall ensure that the supplier's documentation records support the need to replace the accessory to maintain the equipment's functionality and meet the beneficiary's medical need. In the event that certain accessories are furnished for the first time, such as a heated humidifier or heated tubing, contractors shall ensure that the accessories are medically necessary. This guidance for replacement of essential accessories is to be applied to only CPAP devices and RADs owned by Medicare beneficiaries when Medicare initially paid for the base DME item. This guidance does not apply to CPAP devices or RADs when Medicare did not originally provide payment for the base item. In cases where Medicare did not originally pay for the DME item, all coverage, coding and documentation requirements in effect for the date of service on the claim under review must be met.
When making a payment determination, Medicare contractors are to only review the necessity of replacing a CPAP device or RAD accessory when the base beneficiary-owned CPAP device or RAD continued medical need requirements are met.
This policy DOES NOT apply to replacement of accessories for a CPAP device or RAD that has been used for less than 13 months of continuous use or for replacement of accessories for a CPAP device or RAD that is owned by the beneficiary but was not purchased by Medicare. In these cases, all medical necessity documentation needed for the initial use of the CPAP device or RAD must be furnished, but the 120 day grace period above would apply for transitions to contract suppliers at the start of the Round 2 Recompete.
Questions presented to Noridian
1.) Is CMS referring to a WOPD below? Since we can’t get a WOPD after delivery for items that require one, does the grace period only apply to the detailed written order and other supporting documents prior to billing, or are they talking about the WOPD? That really needs to be clearly stated.
2.) What guidelines will CERT follow? Does this grace period only apply to the DME MACs?
3.) In reference to supplies, it states, “contractors shall only review (1) the base DME item continued use and continued medical need requirements; and (2) the medical necessity of the replacement of specific accessories or furnishing of new accessories and whether they are essential for the effective use of the base DME.” So, does this mean we only have to obtain a prescription to establish the ongoing medical necessity of the item? Suppliers need to know exactly what documents are expected to be in the file.
4.) For the replacement accessories used with a beneficially owned CPAP or RAD, does this apply to ALL contractors that would be auditing our claims?
5.) Suppliers really need to know what they are expected to have on file by November 1, 2016.