Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

Medicare guidance says Section 424.57(c)(12) requires suppliers, as part of their standards to be met for enrollment and participation, to maintain proof of delivery documentation in their files. In certain instances, compliance with proof of delivery may be required as a condition of payment, and must be available to the DME MAC, RAC, SMRC, CERT, and ZPIC/UPIC on request. For such items, if the supplier does not have appropriate proof of delivery documentation within the prescribed timeframes, associated claims will be denied and overpayments recouped. We note that non-compliance with supplier standards may also result in revocation from the Medicare program. Suppliers who consistently do not provide documentation to support their services may be referred to the OIG or NSC for investigation and/or imposition of sanctions. If the beneficiary is newly eligible to the Medicare program, the proof of delivery standards require the supplier to obtain a statement, signed and dated by the beneficiary (or beneficiary's designee), that the supplier has examined the item. Any person who can sign and accept the delivery of durable medical equipment on behalf of the beneficiary. Suppliers, their employees, or anyone else having a financial interest in the delivery of the item are prohibited from signing and accepting an item on behalf of a beneficiary (i.e., acting as a designee on behalf of the beneficiary). The signature of the designee should be legible. If the signature of the designee is not legible, the supplier/shipping service should note the name of the designee on the delivery slip. Three methods of delivery are: Supplier delivering directly to the beneficiary or designee; Supplier utilizing a
delivery/shipping service to deliver items; and Delivery of items to a nursing facility on behalf of the
beneficiary. The date of delivery may be entered by the beneficiary, designee or the supplier. As a
general Medicare rule, the date of service shall be the date of delivery. Exceptions are made for suppliers
who use a delivery/shipping service. If the supplier uses a delivery/shipping service, the supplier may use
the shipping date as the date of service on the claim. The shipping date may be defined as the date the
delivery/shipping service label is created or the date the item is retrieved for delivery; however, such
dates should not demonstrate significant variation. (See Pub. 100-08, chapter 5, section 5.2.4 for further
information on written orders prior to delivery.) You can find this guidance in the Medicare Program Integrity Manual Chapter 5 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, 5.10 - Supplier Documentation; Medicare Program Integrity Manual Chapter 4 - Program Integrity, Section 4.26 - Supplier Proof of Delivery Documentation Requirements, Subsection 4.26.1 - Proof of Delivery and Delivery Methods.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.