Requirements for Processing VA Durable Medical Equipment

1.1.2 – Requirements for Processing VA Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) Claims (Rev. 11427; Issued: 05-20-22; Effective: 01-01-23; Implementation: 01-03-23) NOTE: CMS seeks to reduce burden and modernize processes to ensure a reduction in improper payments and an increase in customer satisfaction. The Certificate of Medical Necessity (CMN) form and DME Information Form (DIF) were originally required to help document the medical necessity and other coverage criteria for selected Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items. In the past, a supplier received a signed CMN from the treating physician or created and signed a DIF to submit with the claim. Due to improvements in claims processing and medical records management, the information found on CMNs or DIFs is available either on the claim or in the medical record and is redundant. Therefore, to reduce burden and increase customer satisfaction, providers and suppliers no longer need to submit these forms for services rendered after January 1, 2023. • For claims with dates of service on or after January 1, 2023 – providers and suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic filing requirements, claims received with these forms attached will be rejected and returned to the provider or supplier. • For claims with dates of service prior to January 1, 2023 – processes will not change and if the CMN or DIF is required, it will still need to be submitted with the claim, or be on file with a previous claim. This statement applies throughout the Program Integrity Manual wherever CMNs and DIFs are mentioned. The process of receiving VA DMEPOS claims for a no-pay Electronic Medicare Remittance Advice (e-MRA) is effective on April 1, 2018. The processing of these claims, as with the Part A and Part B claims, allows for a CMS no-pay e-MRA to be generated for all DMEPOS claims submitted to CMS by the VA. VA DMEPOS claims are processed by a single DME MAC. For VA DMEPOS claims the e-MRA displays the amount that Medicare would have paid for the claim using the same fee schedule payments as DMEPOS Medicare claims would’ve paid and are based on the beneficiary’s state of residence. The same deductible and coinsurance rules applicable to Medicare are applied to the VA claims and are provided on the e-MRA. The VA submits DMEPOS claims via the ANSI X12 837P electronic format. The VA claims will be processed through the Medicare DME MAC Common Electronic Data Interchange (CEDI) front end system, DMEPOS claims processing system (VMS) and the common working file (CWF). In addition to following the ANSI X12 837P standards for claims submissions the following criteria applies: • The VA's submitter of record is the approved biller and submits all VA electronic claims to CEDI. • The VA supplies CMS, the VA DME MAC and CEDI with the VA facility NPI list. Validation of the NPI is done at the CMS front end contractor. • VA claims are processed as mandatory assigned claims, no beneficiary submitted claims will be processed. • VA DMEPOS submitted claims must be for beneficiaries that reside in the US and its territories. • The VA must submit claims for Medicare approved HCPCS provided on the DMEPOS jurisdiction list which can be found at https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME- Center.html. • The VA DMEPOS claims are subject to the Medicare timely filing rules. Claims will be accepted for processing with dates of service one year prior to the date of receipt. • The VA will submit paper CMNs for DMEPOS items that require a CMN per Medicare rules. The CMNs will be faxed (until the time VA has the ability to submit CMNs electronically) to the DME MAC. Claims requiring a CMN may be held for up to 2 weeks to allow for receipt of the CMN. Claims will be denied if a CMN is not received within 2 weeks. The CWF edits to ensure the same three conditions stated above for A/B claims are applicable and must be present for adjudication on the DMEPOS claims. In addition, MSP claims are accepted from the VA and the CWF will apply MSP editing to VA DMEPOS claims. Finalized claims will be included in the VA e-MRA and produced in the CMS flat file format. CEDI will translate the VA e-MRA flat file to the ANSI X12 835 format and make the file(s) available for the VA’s submitter of record to retrieve. Adjustments to claims submitted by the VA can be made only for redeterminations or cancels. This applies to all DMEPOS claims submitted by the VA for VA facilities and for independent suppliers.