DME Billing Services

Prior Authorization Process for DME during COVID-19 – Provider Burden Relief FAQs

The importance of medical review activities to CMS’ program integrity efforts, CMS will stop exercising enforcement discretion for the Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items beginning on August 3, 2020, regardless of the status of the public health emergency.

Is CMS suspending most Medicare Fee-For-Service (FFS) medical review during the Public Health Emergency (PHE) for the COVID-19 pandemic?

Yes, CMS had suspended most Medicare Fee-For-Service medical review during the COVID-19 period. This includes:

  • Pre-payment medical review conducted by MACs
  • Post-Payment reviews conducted by MACs
  • Supplemental Medical Review Contractor (SMRC) Reviews
  • Recovery Audit Contractor (RAC)

No additional documentation request will be placed during the COVID-19 emergency period. Targeted probe and Educate reviews that are in process will be suspended and claims will be paid. All current post-payment MAC, SMRC, and RAC reviews will be suspended and released from review.

This suspension of review activity is for the duration of the public emergency period only. However, CMS reserve the right to conduct medical review during or after a pandemic situation if there is an indication of potential fraud.

Is CMS waiving signature requirements on proof of delivery slips in response to the COVID-19 pandemic, for Dates of Service (DOS) within the PHE for the COVID-19 pandemic?

Yes, CMS is waiving signature requirements due to the inability to collect signatures during this pandemic situation. CMS will not enforce the signature requirements. Typically, Part B drugs and certain DME covered by Medicare require proof of delivery and or a beneficiary’s signature. Suppliers can document in the medical record the appropriate date of delivery and signature was not able to obtain due to public emergency.

Is CMS pausing the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model?

Yes, from March 29, 2020, certain claims processing requirements for the repetitive, non-emergent ambulance transport prior authorization model will be on hold in the model states of Delaware, the District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carola, Virginia, and West Virginia until the public health emergency for the COVID-19 pandemic has ended.

During this hold, claims for repetitive, scheduled non-emergent ambulance transports submitted on or after March 29, 2020, and before the end of public health emergency in these states will not be stopped for pre-payment review, if prior authorization has not been requested by the fourth-round trip in 30 days.

The MAC will continue to review any prior authorization requests that have already been submitted. Some claims will be excluded from the future medical review that has received a provisional affirmative prior authorization decision and are submitted and affirmed UTN (Unique Tracking Number).

The model is currently scheduled to end on December 1, 2020. Given this pause, will CMS extend the model beyond that date?

At present, CMS is not planning an extension beyond December 1, 2020. If this did occur, CMS will issue a proper public notice for the same. This model will not be expanded in any other state during this emergency period.

How does this pause in the model affect a determination as to whether the model meets the criteria to be expanded nationwide, as provided under section 1834(l)(16) of the Social Security Act and any next steps for expansion?

This pause in the model does not impact on the efforts to expand the model nationwide as provided under section 1843(l)(16). According to CMS, they will continue their efforts to prepare for expansion after the PHE for the COVID-19 pandemic has ended.

How does this pause in the model affect the evaluation of the model?

The pause for the PHE for the COVID-19 will take into consideration while evaluating this model. Those claims will be reviewed through post-payment review and will still be factored into the evaluation.

Is CMS pausing the Review Choice Demonstration for Home Health Services?

Yes. Effective March 29, 2020, certain claims processing for the Review Choice Demonstration (RCD) for Home Health Services will be paused in Illinois, Ohio, and Texas, until the PHE for the COVID-19 pandemic has ended. During the pause, the MACs will process claims submitted prior to the emergency period under normal claims processing requirements.

Claims for home health services furnished on or after March 29, 2020, and before the end of the PHE for the COVID-19 pandemic in these states will not be subject to the review choices made by the home health agency under the demonstration. The demonstration will not begin in North Carolina and Florida on May 4, 2020, as previously scheduled. CMS will provide notice on its demonstration website rescheduling the start of the demonstration, once the PHE has ended.

The demonstration is currently scheduled to end on May 31, 2024. Given this pause, will CMS extend the demonstration beyond that date?

No, CMS is not planning an extension beyond May 31, 2024. If this did occur, CMS would provide proper public notice.

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