Advance Determination
Jim DeWees
Description
Collection
Title:
Advance Determination
Creator:
Jim DeWees
Date:
1/25/2013
Text:
Does ANYONE know about this? Has anyone tried doing this?
Below is the copy from Chapter 5 (you can just click on the link at the
bottom of the NGS Email that I forwarded earlier today.
But I wanted to copy this section for everyone to see, and let's talk about
this.....This sounds like what we ALL NEED TO BE DOING!!
Below is the Advance Determination section...related to customized
DME....to me, Prosthetics and Orthotics fit this definition. But has
anyone taken this to task?
5.15 – Definition of Customized DME
(Rev. 167, Issued: 10-27-06; Effective: 10-01-06; Implementation: 10-02-06)
Section 1834(a)(4) of the Act and 42 CFR 414.224 define customized DME as
being items of DME which have been uniquely constructed or substantially
modified for a specific beneficiary according to the description and orders
of the beneficiary's treating physician.
For instance, a wheelchair which has been; (1) measured, fitted, or adapted
in consideration of the patient's body size, disability, period of need, or
intended use, (2) assembled by a supplier or ordered from a manufacturer who
makes available customized features, modifications, or components for
wheelchairs, and (3) is intended for an individual patient's use in
accordance with instructions from the patient's physician would be
considered “customized.
5.16 – Advance Determination of Medicare Coverage (ADMC) of Customized DME
(Rev. 167, Issued: 10-27-06; Effective: 10-01-06; Implementation: 10-02-06)
Section 1834(a)(15)(C) of the Act provides that carriers shall, at the
request of a supplier or beneficiary, determine in advance of delivery of an
item whether payment for the item may not be made because the item is not
covered if:
The item is a customized item,
The patient to whom the item is to be furnished, or the supplier, requests
that such advance determination be made, and
The item is not an inexpensive item as specified by the Secretary.
This section provides for direction in implementing §1834 (a)(15)(C) of the
Act.
It is important to note that ADMCs are not initial determinations as defined
at 42 CFR 405.801(a), because no request for payment is being made. As such,
an ADMC cannot be appealed.
This is a voluntary program. Beneficiaries and suppliers are not required to
submit ADMC requests in order to submit claims for items. Additionally, DME
PSCs may not require an ADMC request as a prerequisite for submitting a
claim.
5.16.1 – Items Eligible for ADMCs
(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)
The DME MACs shall publish examples of the types of items for which ADMCs
are available. These examples shall be published yearly in the DME MAC’s
Supplier Manual or yearly in the DME MAC’s Supplier Bulletin. Examples will
be published in the form of HCPCS codes eligible for this program. Because
HCPCS codes describe general “categories of equipment, this list is not a
list of specific items, but rather a general list of the categories of types
of items eligible for this program.
5.16.2 – Instructions for Submitting ADMC Requests
(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)
Suppliers or beneficiaries may submit, in hard copy, requests for ADMC.
Requests must contain adequate information from the patient's medical record
to identify the patient for whom the item is intended, the intended use of
the item, and the medical condition of the patient that necessitates the use
of a customized item. Each DME MAC shall publish the mailing address to
which requests should be sent.
5.16.3 – Instructions for Processing ADMC Requests
(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)
Once a request is received, the DME MAC shall determine if there is
sufficient medical documentation that supports whether the item is
reasonable and necessary. In addition, a review of the beneficiary’s claims’
history should be conducted in order to determine whether any other reason
exists to cause the claim to be denied, e.g., whether the same or similar
equipment has already been provided.
Upon receipt of a request, the DME MAC shall render an advance determination
of Medicare coverage within 30 calendar days. DME MACs shall provide the
requestor with their decision, be it affirmative or negative, in writing.
If requests are received for the wrong item(s), the request will be
rejected. Rejected requests should not be counted as workload.
Requests for appropriate items received without documentation to support
coverage will be denied as not meeting the medical necessity requirements
Medicare has established for the item.
5.16.4 – Affirmative ADMC Decisions
(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)
When making an ADMC, the DME MAC should review the information submitted
with the request to determine; 1) if a benefit category exists, 2) if a
statutory exclusion exists, and 3) if the item is reasonable and necessary.
An affirmative ADMC decision will provide the supplier and the beneficiary
assurance that the beneficiary, based on the information submitted with the
request, will meet the medical necessity requirements Medicare has
established for the item. An affirmative ADMC decision does not provide
assurance that the beneficiary meets Medicare eligibility requirements nor
does it assure that any other Medicare requirements (MSP, etc.) have been
met. Only upon submission of a complete claim, can the DME MAC make a full
and complete determination.
An affirmative ADMC decision does not extend to the price that Medicare will
pay for the item.
An affirmative ADMC decision is valid for a period of 6 months from the date
the decision is rendered. Oftentimes, beneficiaries who require customized
DME are subject to rapid changes in medical condition. These changes may
obviate the need for a particular item, either because the beneficiary's
condition improved or deteriorated. For this reason, the date the item was
provided to the beneficiary cannot be more than 6 months after the date the
ADMC decision was made.
The DME MACs reserve the right to review claims on a pre- or post-payment
basis and, notwithstanding the requirements of this section, may deny claims
and take appropriate remedy if they determine that an affirmative ADMC
decision was made based on incorrect information.
-----Original Message-----
From: Wil
Sent: Friday, January 25, 2013 3:06 PM
To: <Email Address Redacted>
Subject: [OANDP-L] Medicare documentation
Hello Colleagues & Guests,
It has been brought to my attention that the Jurisdiction DME MAC email
entitled Documentation for K Levels for Prosthetics, dated 01/24/13, may
have some very important information included. As such, I would ask
several of you to review this documentation and report your findings. At
the bottom of the email is a link to a Medicare Integrity Manual. I have
not read the information yet, but will this weekend. What I am hearing
is that Medicare has to allow us to request a prior authorization for
custom prosthetic care. If that is true, that is huge.
It would be nice if some on this listserve would take the time to review
this document and let us know what your thoughts are.
Thanks for your consideration.
Wil Haines, CPO
MaxCare Bionics
Avon, IN 46123
Below is the copy from Chapter 5 (you can just click on the link at the
bottom of the NGS Email that I forwarded earlier today.
But I wanted to copy this section for everyone to see, and let's talk about
this.....This sounds like what we ALL NEED TO BE DOING!!
Below is the Advance Determination section...related to customized
DME....to me, Prosthetics and Orthotics fit this definition. But has
anyone taken this to task?
5.15 – Definition of Customized DME
(Rev. 167, Issued: 10-27-06; Effective: 10-01-06; Implementation: 10-02-06)
Section 1834(a)(4) of the Act and 42 CFR 414.224 define customized DME as
being items of DME which have been uniquely constructed or substantially
modified for a specific beneficiary according to the description and orders
of the beneficiary's treating physician.
For instance, a wheelchair which has been; (1) measured, fitted, or adapted
in consideration of the patient's body size, disability, period of need, or
intended use, (2) assembled by a supplier or ordered from a manufacturer who
makes available customized features, modifications, or components for
wheelchairs, and (3) is intended for an individual patient's use in
accordance with instructions from the patient's physician would be
considered “customized.
5.16 – Advance Determination of Medicare Coverage (ADMC) of Customized DME
(Rev. 167, Issued: 10-27-06; Effective: 10-01-06; Implementation: 10-02-06)
Section 1834(a)(15)(C) of the Act provides that carriers shall, at the
request of a supplier or beneficiary, determine in advance of delivery of an
item whether payment for the item may not be made because the item is not
covered if:
The item is a customized item,
The patient to whom the item is to be furnished, or the supplier, requests
that such advance determination be made, and
The item is not an inexpensive item as specified by the Secretary.
This section provides for direction in implementing §1834 (a)(15)(C) of the
Act.
It is important to note that ADMCs are not initial determinations as defined
at 42 CFR 405.801(a), because no request for payment is being made. As such,
an ADMC cannot be appealed.
This is a voluntary program. Beneficiaries and suppliers are not required to
submit ADMC requests in order to submit claims for items. Additionally, DME
PSCs may not require an ADMC request as a prerequisite for submitting a
claim.
5.16.1 – Items Eligible for ADMCs
(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)
The DME MACs shall publish examples of the types of items for which ADMCs
are available. These examples shall be published yearly in the DME MAC’s
Supplier Manual or yearly in the DME MAC’s Supplier Bulletin. Examples will
be published in the form of HCPCS codes eligible for this program. Because
HCPCS codes describe general “categories of equipment, this list is not a
list of specific items, but rather a general list of the categories of types
of items eligible for this program.
5.16.2 – Instructions for Submitting ADMC Requests
(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)
Suppliers or beneficiaries may submit, in hard copy, requests for ADMC.
Requests must contain adequate information from the patient's medical record
to identify the patient for whom the item is intended, the intended use of
the item, and the medical condition of the patient that necessitates the use
of a customized item. Each DME MAC shall publish the mailing address to
which requests should be sent.
5.16.3 – Instructions for Processing ADMC Requests
(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)
Once a request is received, the DME MAC shall determine if there is
sufficient medical documentation that supports whether the item is
reasonable and necessary. In addition, a review of the beneficiary’s claims’
history should be conducted in order to determine whether any other reason
exists to cause the claim to be denied, e.g., whether the same or similar
equipment has already been provided.
Upon receipt of a request, the DME MAC shall render an advance determination
of Medicare coverage within 30 calendar days. DME MACs shall provide the
requestor with their decision, be it affirmative or negative, in writing.
If requests are received for the wrong item(s), the request will be
rejected. Rejected requests should not be counted as workload.
Requests for appropriate items received without documentation to support
coverage will be denied as not meeting the medical necessity requirements
Medicare has established for the item.
5.16.4 – Affirmative ADMC Decisions
(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)
When making an ADMC, the DME MAC should review the information submitted
with the request to determine; 1) if a benefit category exists, 2) if a
statutory exclusion exists, and 3) if the item is reasonable and necessary.
An affirmative ADMC decision will provide the supplier and the beneficiary
assurance that the beneficiary, based on the information submitted with the
request, will meet the medical necessity requirements Medicare has
established for the item. An affirmative ADMC decision does not provide
assurance that the beneficiary meets Medicare eligibility requirements nor
does it assure that any other Medicare requirements (MSP, etc.) have been
met. Only upon submission of a complete claim, can the DME MAC make a full
and complete determination.
An affirmative ADMC decision does not extend to the price that Medicare will
pay for the item.
An affirmative ADMC decision is valid for a period of 6 months from the date
the decision is rendered. Oftentimes, beneficiaries who require customized
DME are subject to rapid changes in medical condition. These changes may
obviate the need for a particular item, either because the beneficiary's
condition improved or deteriorated. For this reason, the date the item was
provided to the beneficiary cannot be more than 6 months after the date the
ADMC decision was made.
The DME MACs reserve the right to review claims on a pre- or post-payment
basis and, notwithstanding the requirements of this section, may deny claims
and take appropriate remedy if they determine that an affirmative ADMC
decision was made based on incorrect information.
-----Original Message-----
From: Wil
Sent: Friday, January 25, 2013 3:06 PM
To: <Email Address Redacted>
Subject: [OANDP-L] Medicare documentation
Hello Colleagues & Guests,
It has been brought to my attention that the Jurisdiction DME MAC email
entitled Documentation for K Levels for Prosthetics, dated 01/24/13, may
have some very important information included. As such, I would ask
several of you to review this documentation and report your findings. At
the bottom of the email is a link to a Medicare Integrity Manual. I have
not read the information yet, but will this weekend. What I am hearing
is that Medicare has to allow us to request a prior authorization for
custom prosthetic care. If that is true, that is huge.
It would be nice if some on this listserve would take the time to review
this document and let us know what your thoughts are.
Thanks for your consideration.
Wil Haines, CPO
MaxCare Bionics
Avon, IN 46123
Citation
Jim DeWees, “Advance Determination,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 24, 2024, https://library.drfop.org/items/show/234433.
