Suppliers Documentation for DMEPOS Repair Claims

5.10.1 - Suppliers Documentation for DMEPOS Repair Claims (Rev. 10190; Issued: 06-19-2020; Effective: 01-01-2020; Implementation: 07-01- 2020) When reviewing DMEPOS claims for repairs, the contractor shall review for continued medical necessity of the item and necessity of the repair. Contractors are not required to determine that the requirements for provision of the DMEPOS item as when it was originally ordered were met. For example, even though a face-to-face encounter is required for the initial provision of certain wheelchairs, it is not needed for the repair of a wheelchair already covered and paid for by Medicare. However, documentation from the treating practitioner that indicates the wheelchair being repaired continues to be medically necessary is required. For this purpose, documentation is considered timely when it is on record in the preceding 12 months, unless otherwise specified in relevant Medicare policy. In addition, the contractor shall ensure that the supplier’s record includes the nature of the repair required and work performed to restore the item to its functionality to meet the Medicare beneficiary’s medical need. These instructions do not replace or alter other longstanding instructions related to coverage and payment for reasonable and necessary repairs and maintenance and servicing of DMEPOS items. Contractors shall continue to adhere to these program policies and procedures. Examples include, but are not limited to, Chapter 15, section 110.2 of the Benefit Policy Manual and Chapter 20, sections 10.2 and 40 of the Claims Processing Manual. Contractors are also reminded that parts and labor covered under a manufacturer or supplier warranty are not to be considered reasonable and necessary under regulation; therefore, contractors shall determine for each claim whether billed parts and labor are covered under a warranty. For reasonable and necessary parts, payment is made on a lump sum basis based on the contractor’s individual consideration of a reasonable payment amount for the part. For reasonable and necessary labor, payment is based on a reasonable fee established by the contractor for labor associated with repairing the item.